In our institution,
over the 5-year time period,
our PCs had a technical success > 90%,
in keeping with published standards [4] with no immediate complications following PC.
Based on the most recent Tokyo Guidelines [7],
initial management with antibiotics and supportive care is recommended across all 3 grades of severity [5].
If there is a failure of this conservative management,
then PC can be considered [5],
with the suggested time being after 3 days of conservative management [2,
6].
In our centre,
the mean time from admission to performing the PC was 3.4 days.
Although no clinical observation data was available to gauge the response to antibiotic therapy,
the biochemical data suggests a failure to improve.
This is seen in the inflammatory markers,
where the WCC remained persistently elevated and a significant increase in the CRP levels from admission to pre-procedure.
It can therefore be inferred that the initial conservative treatment alone was not adequate.
Following a PC,
our data demonstrated a statistically significant decrease in both the WCC (figure 2) and CRP levels (figure 3) at 1-2 days post-procedure,
with the CRP levels continuing to significantly decrease relative to the pre-procedure value at 3-4 and 5-7 days.
This drop in inflammatory markers at 1-2 days could be explained by the PC reducing the septic burden to the patient, and therefore allowing conservative measures including antibiotics to aid in combatting the infection.
With regards to the microbiological analysis,
80% of the samples obtained cultured pathogens resistant to antibiotics,
most commonly to co-amoxiclav and amoxicillin (figure 1).
This is particularly important in our institution as our antibiotic guidelines recommend intravenous co-amoxiclav as the first line antibiotic in patients that are not allergic to penicillin; with regimen of amoxicillin,
temocillin,
metronidazole and a single gentamicin dose (renal function permitting) for patients with severe infection.
It is therefore possible to make the inference that owing to antimicrobial resistance noted in our sample size,
initial conservative management was likely to be ineffective in some of our patients who subsequently proceeded to have a PC.
The bilirubin levels were seen to follow a downward trend following the procedure with a statistically significant decrease at 1-2,
3-4 days and 5-7 days (figure 4).
The likely explanation of this would be relief of the infected obstructed biliary system following PC insertion.
No significant difference was seen in the serum ALP and ALT levels.
We noted that the mean time from procedure to discharge was 9.9 days,
which when combined with the mean time from admission to procedure,
results in a total mean length of stay of 13.3 days.
The length of stay in our current study is comparable to recent studies which state a median length of stay of 10 days [8] and 11.4 days [9].
In conclusion,
we have shown that PC performed in our institution is done following a failure to improve on initial conservative management in high risk individuals.
This may well be due to an increase in antimicrobial resistance,
with an improvement in inflamatory markers post-procedurally.
The average length of stay is comparable to recent studies.
Further work needs to be done to provide more information and data on PC to establish its role in managing acute calculous cholecystitis.