Keywords:
Abdomen, Gastrointestinal tract, Interventional non-vascular, Ultrasound, CT, MR, Drainage
Authors:
T. Peachey, J. Smith, H. Nathani, F. Lee; Sheffield/UK
DOI:
10.1594/ecr2018/C-2008
Conclusion
The UK National Institute for Health and Clinical Excellence (NICE) guideline on the management of acute cholecystitis [2] states that percutaneous cholecystostomy should be offered to manage gallbladder empyema for patients in whom surgery is contraindicated at presentation and conservative management is unsuccessful. It should only be offered for patients with moderate or severe cholecystitis. The Tokyo guidelines grade cholecystitis into mild,
moderate and severe [1].
Patients may not be a surgical candidate for a number of reasons,
including multiple comorbidities,
poor overall physical health,
patients requiring haemodialysis or requiring intensive care [3]. Patients who are not suitable for surgery should initially be trialled with 72 hours of medical therapy including antibiotics,
fluids and pain relief [2,3]. If the patient fails to improve after 72 hours and the cholecystitis is moderate or severe (Tokyo grade 2 or 3) percutaneous cholecystostomy should be considered [1].
In our study,
98% of cholecystostomies performed in 2016 were inserted in patients with moderate or severe cholecystitis. This is an excellent result,
demonstrating that in collaboration with our clinical colleagues we are selecting the right patients for cholecystostomy. However,
only 59% of the patients had had signs and symptoms of cholecystitis for three days or more. This could suggest that we were performing cholecystostomies too early. After discussions with consultant radiologists and consultant hepatobiliary surgeons at our centre,
it was thought valid that a senior clinical assessment could overrule the guideline and on occasion patients may need cholecystostomy sooner than at 72 hours.
In total 151 patients underwent cholecystostomy during the three year study period,
an average of slightly less than one cholecystostomy per week. Three quarters of cholecystostomies were inserted Monday to Friday between 7am and 7pm. Our data suggest that direct insertion is more common than transhepatic.
There were a variety of referral sources for cholecystostomy. Patients directly under the care of a general surgeon accounted for 75% of referrals. Patients from non-surgical specialties should have a senior surgical review (senior specialist trainee or consultant) prior to cholecystostomy.
In summary,
percutaneous cholecystostomy insertion is performed in appropriate patients at our centre. On imaging performed prior to cholecystostomy,
over half demonstrated gallstones, a third were found to have a perforated gallbladder,
and only 8% had a liver abscess. The majority of cholecystostomies were performed within normal working hours. Percutaneous cholecystostomy is an effective management tool for acute cholecystitis.