INVITED ARTICLE


https://doi.org/10.5005/jp-journals-10030-1397
Panamerican Journal of Trauma, Critical Care & Emergency Surgery
Volume 11 | Issue 3 | Year 2022

The use of Percutaneous Tubes for Management of Acute Cholecystitis


Erik J Teicher1, Paula A Ferrada2

1,2Trauma Acute Care Surgery (TACS), Inova Health System, Falls Church, Virginia, United States

Corresponding Author: Erik J Teicher, Trauma Acute Care Surgery (TACS), Inova Health System, Falls Church, Virginia, United States, Phone: +17037762274, e-mail: erik.teicher@inova.org

Received on: 03 October 2022; Accepted on: 31 October 2022; Published on: 31 December 2022

ABSTRACT

Percutaneous cholecystostomy (PC) tubes have been used in the management of acute cholecystitis (AC) as an alternative to cholecystectomy for decades. We place the management of AC into a structure based on the Tokyo guidelines. We then generally review the PC tubes and their appropriateness in the treatment of AC. Finally, we provide an algorithm when approaching patients with AC. This is an important topic as it is one of the common problems encountered in acute care surgery. Standardization of the care we provide to these patients can only lead to improved outcomes.

How to cite this article: Teicher EJ, Ferrada PA. The Use of Percutaneous Tubes for Management of Acute Cholecystitis. Panam J Trauma Crit Care Emerg Surg 2022;11(3):145-150.

Source of support: Nil

Conflict of interest: Dr Paula A Ferrada is associated as the Editorial Board Member of this journal and this manuscript was subjected to this journal’s standard review procedures, with this peer review handled independently of the Editor-in-Chief and his/her research group.

Keywords: Acalculous, Calculous, Cholecystectomy, Cholecystitis, Cholecystostomy, Gallbladder, Gallstones.

BACKGROUND

Acute cholecystitis represents an acute inflammation of the gallbladder caused by an obstruction of the cystic duct. Acute calculous cholecystitis (ACC), due to the presence of gallstones, represents the most common cause present in approximately 90–95% of patients with AC.1 Gallbladder disease affects approximately 20 million people in the United States, with more than 200,000 people diagnosed with AC annually, and is directly responsible for greater than $6.3 billion in healthcare funds per year.2 About 80% of adults with gallstones are asymptomatic and 20% will ultimately develop gallstone disease with ACC as the initial presentation in 10–15% of patients.3,4 Acute acalculous cholecystitis (AAC), where inflammation develops in the absence of gallstones, is due to the sloughing of the gallbladder mucosa, is less common and seen in approximately 5–10% of patients.5 AAC can affect about 0.5–18% of critically ill patients, especially those who become critically ill following cardiac surgery, abdominal vascular surgery, and severe trauma.6 Predisposing factors for AAC include major cardiovascular disorders, diabetes mellitus, human immunodeficiency virus infection, autoimmune disorders, and the use of total parenteral nutrition. It is also more common in men than women and patients over 50 years.

There is no single clinical, laboratory, or imaging finding sufficient to establish the diagnosis of AC by itself.7 Therefore, a combination of detailed clinical history, physical examination, laboratory tests, and imaging is required to make the diagnosis. Constant right upper quadrant abdominal pain, with or without association with food intake, is a strong clinical indicator of this disease. Fever, nausea, and vomiting are typical. Right upper quadrant tenderness or mass are potential physical examination findings. The presence of Murphy’s sign, an arrest of inspiration during palpation of the right upper quadrant, is pathognomonic for AC. Leukocytosis and elevated C-reactive protein may be seen.

Right upper quadrant ultrasound (US) is the initial imaging modality of choice for the evaluation of suspected AC because of its low-cost, wide availability, short examination duration, absence of ionizing radiation, sensitivity of 91%, and specificity of 80%.8 US can typically demonstrate, in addition to gallstones and sludge, gallbladder wall thickening, gallbladder distention, and pericholecystic fluid.

Additional imaging is suggested for the diagnosis of AC in selected patients. Computed tomographic (CT) imaging has an estimated sensitivity of 94% and a specificity of 59%.7 CT findings associated with AC include gallbladder wall thickening, gallbladder distention, pericholecystic fluid, and pericholecystic fat stranding. The detection of gallstones with CT is dependent on the gallstone composition, as at least 20% of gallstones have similar attenuation as bile, therefore, remaining undetectable.9 Hepatobiliary iminodiacetic acid (HIDA) imaging using nuclear medical techniques involves intravenous injection of technetium-99m attached to iminodiacetic acid, which is then fully excreted into the biliary system, while a camera acts as a nuclear detector and forms an image. HIDA scans have a sensitivity of 97% and a specificity of 94% for the diagnosis of AC.10 The reason for its superior accuracy is that HIDA imaging detects obstruction of the cystic duct, which is the precipitating event for AC, resulting in nonvisualization of the gallbladder. Therefore, it is also the most reliable imaging study for patients with suspected acalculous cholecystitis.11 Magnetic resonance imaging (MRI) findings associated with AC include gallstones, gallbladder wall thickening, gallbladder wall edema, gallbladder distention, pericholecystic fluid, and perihepatic fluid.12 The presence of one or more of these findings indicates AC with a sensitivity of 88% and specificity of 89%.13 Additionally, MRI can be utilized to evaluate choledocholithiasis, which can assist in the management planning of common bile duct stones.

Acute cholecystitis must be differentiated from other diagnoses causing similar signs and symptoms. Symptomatic cholelithiasis is a cause of right upper quadrant abdominal pain due to a gallstone obstructing the cystic duct, but with the absence of other clinical, laboratory, or imaging findings consistent with ACC. This pain typically follows a meal and becomes resolved after the gallstone becomes nonobstructive within a few hours. Common bile duct stones, acute cholangitis, acute pancreatitis, acute gastritis, peptic ulcer disease, and myocardial infarction should be considered in the differential diagnosis.

The Tokyo guidelines were established to help improve the diagnosis of AC. These guidelines, most recently updated in 2018, combined the presence of local signs of inflammation, systemic signs of inflammation, and imaging findings to help diagnose AC with a sensitivity and specificity of 91.2 and 96.9%, respectively (Table 1). The assessment criteria in severity grading for AC have been validated and are significantly associated with increased mortality, increased hospital length of stay, higher conversion to open cholecystectomy (OC), and greater cost.14 Once the definitive diagnosis of AC is made, the severity can be determined using other physical examination, laboratory, and physiologic parameters (Table 2).

Table 1: The 2018 Tokyo guidelines for diagnosis of AC
Local signs of inflammation
  • Murphy’s sign.

  • Right upper quadrant mass, pain, or tenderness.

Systemic signs of inflammation
  • Fever.

  • Elevated C-reactive protein.

  • Leukocytosis.

Imaging findings
  • Gallstones or related debris.

  • Gallbladder wall thickening (≥4 mm).

  • Gallbladder enlargement (long axis ≥ 8 cm and short axis ≥ 4 cm).

  • Pericholecystic fluid.

  • Lines are shadows surrounding the gallbladder.

Suspected diagnosis: 1 local sign plus 1 systemic sign.
Definite diagnosis: 1 local sign plus 1 systemic sign plus 1 imaging finding.
Table 2: The 2018 Tokyo guidelines for severity grade of AC
Grade III (severe) AC
Associated with any one of the following organ systems:
  • Cardiovascular: hypotension requiring ≥5 μg/kg/min dopamine or any dose of norepinephrine

  • Neurological: the decreased level of consciousness

  • Respiratory: PaO2/FiO2 <300

  • Renal: oliguria, Cr < 2.0 mg/dL

  • Hepatic: PT/INR > 1.5

  • Hematologic: thrombocytopenia < 100,000/mm3

Grade II (moderate) AC
Associated with any one of the following:
  • Leukocytosis >18,000/mm3

  • Palpable tender mass of right upper quadrant

  • Duration of symptoms >72 h

  • Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis)

Grade I (mild) AC
Grade I AC does not meet the criteria of grade Ill or grade II AC. It can also be defined as AC in a healthy patient with no organ dysfunction and mild inflammatory changes in the gallbladder.

DISCUSSION

There are several treatment options for ACC, including early or delayed cholecystectomy, interval cholecystectomy following PC, and nonoperative treatment. Early laparoscopic cholecystectomy (LC) has not shown a higher risk of mortality, or morbidity, but has a shortened hospital length of stay as compared to delayed LC and is the preferred surgical approach to the management of ACC.15 Among higher-risk patients, either because of severe ACC or underlying comorbidity, PC has been used as an alternative treatment for those patients that cannot safely undergo early cholecystectomy. The treatment strategy for these patients is not well established despite guidelines being introduced for the management of ACC based on AC severity. Early cholecystectomy is preferred in grade I (mild) and II (moderate) AC, but an early nonoperative approach may be utilized with delayed cholecystectomy in grade I AC if the patient is at a prohibitive surgical risk. If local inflammation increases surgical risk, then either PC or operative gallbladder drainage is recommended in grade II AC. Grade III (severe) AC is accompanied by organ dysfunction and serious local inflammation necessitating appropriate source control with PC, operative drainage, or cholecystectomy. While management guidelines for grade I and III AC were generally agreed upon at an international consensus meeting, it is worth noting that management guidelines for grade II AC were agreed upon by <90% of those in attendance.16

Introduced in 1980,17 PC has been established as safe and effective with a high success rate. PC involves percutaneous catheter placement into the gallbladder lumen under imaging guidance, usually by radiologists, and is intended to decompress an acutely inflamed gallbladder. PC is performed using local anesthetic and aseptic techniques. Generally, an 18 gauge needle is inserted either transhepatic or transperitoneal into the gallbladder lumen under either CT or US guidance (Fig. 1). A small 0.035 Amplatz stiff wire is then inserted through the needle and a 6–10 Fr locking pigtail catheter is placed using a Seldinger method. The more common transhepatic catheter placement offers greater stability of the catheter, decreased risk of bile leak, decreased risk of transcolonic placement, and promotes tract formation. Transhepatic placement can be either subcostal or intercostal, and certainly anatomic considerations may preclude the preferred subcostal route. The subcostal route has a decreased risk of bleeding and pain, and in the intercostal route there is a risk of lung injury and potential biliopleural fistula.18 Gallbladder decompression provides a rapid clinical improvement in AC with >90% of patients within 3 days following PC insertion. While success rates are quite high, mortality for patients that have undergone PC ranges from 4 to 12.7%, which is generally higher than those for LC.19 This success is achieved by decreasing gallbladder inflammation, allowing for the resolution of sepsis, and allowing for improvement of the general condition of potential high-risk patients.

Figs 1A and B: (A) Transhepatic intercostal and (B) transperitoneal PC tube insertion with CT guidance

The Tokyo guidelines address management of AC based on the severity of the inflammatory response, but it does not directly account for causality in the high-risk patient based on either comorbidities or additional physiologic derangements resulting from chronic conditions. Therefore, it is certainly accepted that younger and low-risk patients undergo LC as the preferred treatment for ACC. Those patients that are high-risk due to the severity of AC were recently examined. The mortality did not differ significantly between LC and PC and was 3 and 9%, respectively. Morbidity was 12% in the LC group and 65% in the PC group and most of these were related to hospital length of stay, recurrent biliary disease, repeat interventions, emergency department visits, and readmissions. These results demonstrated that LC is superior to PC in the treatment of high-risk patients based on acute physiology and chronic health evaluation scores (APACHE) II scores of 7–15.20

Percutaneous cholecystostomy seems preferable to LC for the treatment of ACC in high-risk patients based on major comorbidities or serious illnesses. Those patients that are high-risk due to age with potentially higher comorbidities were examined in a recent systematic review. This study demonstrated postoperative outcomes, such as overall and major complications, were significantly higher in the elderly following LC. There is a sevenfold increase in postoperative mortality in the elderly compared to younger patients and this increases by tenfold in patients >80 years. There was as high as a threefold rate of conversion to OC in the elderly with consequential postoperative mortality and morbidity.21 This demonstrates that PC is a better treatment for AC in the elderly. Other large studies have found similar outcomes for elderly patients who underwent LC and found that age is a predictor of worse outcomes. There are higher conversions to OC, longer hospital length of stay, readmissions within 30 days, additional procedures within 30 days, and death. Interestingly, the rates of common bile duct injuries were similar among the younger and older groups, possibly signifying that the increased mortality and morbidity observed was due to patient age and comorbidities rather than the severity of AC. However, elderly patients classified as low in American Society of Anesthesiologists (ASA) categories 1 and 2, signifying lower overall comorbidities, had fewer complications, lower hospital length of stay, and deaths when LC was performed electively.22

Elective LC can be performed in a delayed manner following PC. The safety of LC for ACC, as compared to PC followed by delayed LC, has been examined in those patients with acceptable surgical risk. When retrospectively examining the timing between insertion of PC and delayed LC, fewer conversions to OC, lower operative times, and overall complications, such as bile leaks and intra-abdominal fluid collections, were seen in patients that underwent LC following PC in a delayed manner of 19.9 days (range 14–39 days).23 This was examined more recently in a prospective study and also showed a significantly higher conversion rate to OC, longer operative time, higher intraoperative blood loss, and more frequent bile leaks in those patients that underwent PC and delayed LC as compared with those early cholecystectomy for grade II AC.24 A recent meta-analysis agreed that outcomes were more favorable with delayed LC. This study showed shorter operative times, a lower conversion rate to OC, and less intraoperative blood loss. There was no significant difference in complications, including bile leak and mortality.25

An important decision is required regarding the management of PC in patients with unacceptable surgical risk, as the decision to remove the PC is a challenging issue. The timing should allow for the resolution of gallbladder inflammation and the formation of a fistulous tract to prevent bile leaks. To prevent bile leak and peritonitis, at least 2 weeks for the transhepatic approach and 3 weeks for the transperitoneal approach are required for tract maturation before PC removal.26 This should be performed when the drain output is minimal, nonbilous, and following a transcatheter cholangiogram to ensure patency of the cystic duct (Fig. 2). Readmission following PC removal with recurrent ACC is 21.7–46.7% over a period of 12–37 months, with other studies that have reported lower recurrence rates.27 The most common cause for recurrent ACC was a single large gallstone occluding the cystic duct representing 92% of cases.28 Other predictors of recurrent ACC after PC removal include higher alkaline phosphatase levels at diagnosis and acute myocardial infarction during the index admission.29

Fig. 2: Transcatheter cholangiogram with patency of cystic duct

Those patients who remain in a condition that precludes surgery with a persistent cystic duct obstruction will need to maintain the PC indefinitely with potential risks of dislodgment, superficial infection, patient discomfort, and increased care demands. A recent review has shown that >50% of patients with AC do not undergo delayed elective LC.30 Retrospectively, grade III (severe) AC, AAC, low albumin level, and history of malignancy were factors that predicted failure to undergo elective LC following PC.31 There are several options described for these patients. Percutaneous fluoroscopic guided gallstone removal is performed by serial dilation of the PC up to 22 Fr over a period of 6–8 weeks and successful gallstone removal with possible fragmentation and basket retrieval.32 Though rarely performed, other options for high-risk and palliative patients include the placement of a percutaneous cystic duct stent, cholecystoduodenostomy, or cholecystocholedochostomy.33

There seems to be a lower recurrence rate of AAC compared to ACC when initially managed with PC during the index admission. In a retrospective study, patients that underwent PC for AAC had an 8.3% risk of recurrent AAC and patients that underwent PC for ACC had a 16.1% risk of recurrent ACC over a period of 115 days following PC removal.34 The lower recurrence rates of AAC following PC have also been observed in other studies.35,36 An interesting observational study demonstrated that elective LC was performed on 46.8% of patients that were initially treated with PC for AAC and 97.7% of the remaining patients were successfully treated with PC following removal, with only 2.3% experiencing recurrent AAC when followed for 8 years.37 This suggests that AAC can be a definitive treatment strategy for patients with AAC.

Based on the literature review, PC remains an important tool for the management of AC when used appropriately. AAC may be managed with PC alone as there is a low recurrence rate. The management of ACC is largely based on both the severity grading and surgical risk. In patients with grade I (mild) ACC, those with acceptable surgical risk should undergo early LC, whereas antibiotics alone may be sufficient in patients with high surgical risk, based on comorbidities with evaluation for possible delayed LC if modifiable factors allow for lower surgical risk. In grade II (moderate) ACC, patients with acceptable surgical risk should undergo early LC and those with high surgical risk should undergo early PC. In grade III (severe) ACC, those patients with acceptable surgical risk and physiologically appropriate should undergo early LC and those with either high surgical risk and physiologically inappropriate should undergo early PC or surgical drainage (Flowchart 1).

Flowchart 1: Algorithm for management of AC

CONCLUSION

The definitive treatment for AC remains early LC. However, this may not be appropriate in patients unfit for surgery due to comorbidities or AC severity. Studies have shown that PC is an alternative treatment option for patients who are considered high-risk for surgery due to serious comorbidities or physiologic derangements. In patients that have undergone PC, a decision must be made regarding delayed LC or continual gallbladder drainage with PC. Delayed LC is recommended in patients with modifiable risk factors that decrease surgical risk. In patients that remain a prohibitive surgical risk, a cholangiogram should demonstrate cystic duct patency before removal, and removal should prompt a discussion regarding the recurrence of AC and uncommon additional percutaneous treatment strategies that have been employed in the patient with prohibitive surgical risk and continued cystic duct obstruction. PC should be the definitive therapy for AAC.

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