Effective use of percutaneous cholecystostomy in high-risk surgical patients: techniques, tube management, and results.
HYPOTHESIS: Percutaneous cholecystostomy (PC) is an effective, safe treatment in patients with suspected acute cholecystitis and severe concomitant comorbidity. DESIGN: Retrospective medical record review from March 1989 to March 1998. SETTING: Referral community teaching hospital (450 beds) in rural Wisconsin. PATIENTS: Twenty-two consecutive patients underwent PC tube placement over a 10-year period. Twenty procedures were for acute cholecystitis (14 calculous, 6 acalculous) and 2 were for diagnostic dilemmas. Nineteen (86%) of 22 patients were American Society of Anesthesiologists class 4; 3 (14%) were class 3. INTERVENTIONS: Pigtail catheters (8F-10F) placed by means of ultrasound or computed tomographic localization, with or without fluoroscopic adjunct. MAIN OUTCOME MEASURES: Thirty-day mortality, complications, clinical improvement as determined by fever and pain resolution, normalization of leukocytosis, further biliary procedures required, and outcome after drain removal. RESULTS: Twenty-two patients underwent PC for presumed acute cholecystitis based on ultrasound and clinical findings. All patients received antibiotics prior to PC for 24 or more hours. Thirty-day mortality was 36% (8 patients), reflecting severity of concomitant disease. Minor complications occurred in 3 of 22 patients. Clinical improvement occurred in 18 (82%) of 22 patients-15 (68%) within 48 hours. Follow-up of fourteen 30-day survivors is as follows: 7 (50%) had drains removed because the gallbladder was stone free, 4 (29%) had drains remaining due to persistent stones, 2 (14%) underwent cholecystectomy, and 1 (7%) awaits scheduled surgery. Only 1 (12.5%) of 8 patients developed biliary complications after drain removal, requiring endoscopic retrograde cholangiopancreatography 9 months after drain removal. One patient required urgent cholecystectomy after failure to respond to PC. This patient died of a perioperative myocardial infarction. CONCLUSIONS: Percutaneous cholecystostomy is an effective, safe treatment in patients with suspected acute cholecystitis and severe concomitant comorbidity. Laparoscopic cholecystectomy is recommended as definitive treatment for patients whose risk for general anesthesia improves in follow-up. Drains can be safely removed once all gallstones are cleared. In patients with severe concomitant disease, drains can be left with a low incidence of complications if stones remain.