Percutaneous cholecystostomy “should be reserved for patients with prohibitive risks for surgery,” conclude the authors of the report in the Archives of Surgery for May.
Dr. Kamal M. F. Itani, with the Veterans Affairs Boston Healthcare System in West Roxbury, Massachusetts, and colleagues explain that while cholecystectomy is the standard treatment for acute cholecystitis, percutaneous cholecystostomy is considered a safe alternative for elderly or critically ill patients and may be indicated for severe cases. “This treatment modality, however, is not without a unique spectrum of complications,” they note.
To compare outcomes between percutaneous cholecystostomy and cholecystectomy, the team reviewed their 10-year experience treating 201 patients with acute cholecystitis at their VA center. Percutaneous cholecystostomy using the transhepatic Seldinger technique was performed in 51 cases, while the other 150 patients underwent cholecystectomy.
The cholecystostomy patients were older than the cholecystectomy patients (70 vs 65 year), and had higher alkaline phosphatase levels (198.2 vs 140.1 U/L) and comorbidities (Charlson index scores 3.1 vs 1.0), and were more likely to be American Society of Anesthesiologists (ASA) class 3-4 (73.6% vs 68.7%), the report indicates.
On multivariate analysis, a Charlson comorbidity score of 4 or higher was the only independent predictor of percutaneous cholecystostomy being performed rather than cholecystectomy. “These results indicate that our patients’ comorbid conditions and general medical risks for surgery were more important than the duration or severity of AC (acute cholecystitis) in determining their treatment,” the authors comment.
ICU stays were longer for cholecystostomy patients than cholecystectomy patients (5.9 vs 2.3 days, p=0.008), as were overall hospital stays (20.7 vs 12.1 days, p<0.001).
There were more complications per patient in the cholecystostomy group than cholecystectomy group (2.9 vs 1.9; p=0.01) and readmission rates were higher at 31.4% versus 13.3% (p=0.006), Dr. Itani and colleagues found.
The hazard ratio for death after percutaneous cholecystostomy versus cholecystectomy was 1.75, but this did not reach statistical significance. The only independent predictor of postprocedure death over time was again a Charlson comorbidity index score of 4 or higher.
The team concludes that percutaneous cholecystostomy should be reserved for patients with very high surgical risks, regardless of the severity of acute cholecystitis.
The author of a related commentary notes that a trial comparing percutaneous cholecystostomy versus cholecystectomy in high-risk surgical patients is planned. “Until then, the nuances of surgical decision making in this patient population remain difficult and require thoughtful clinical judgment,” writes Dr. Rocco Orlando III, at Hartford Hospital and the University of Connecticut School of Medicine in Hartford.
Arch Surg 2012;147:416-422.