- Email: [email protected]
Acute cholecystitis: We can drain it!
Gastrointest Interv 2013; 2:47–49
Contents lists available at SciVerse ScienceDirect
Gastrointestinal Intervention journal homepage: www.gi-intervention.org
Review Article
Acute cholecystitis: We can drain it! Hyun-Ki Yoon* a b s t r a c t Laparoscopic cholecystectomy has recently been accepted as the standard treatment for acute cholecystitis patients. The major role of percutaneous transhepatic gallbladder drainage has been temporarily stabilizing the patient’s acute debilitating condition prior to cholecystectomy. However, there have not been any evidence-based treatment guidelines for acute cholecystitis patients. In this article, the author restates the role of percutaneous transhepatic gallbladder drainage in patients with acute cholecystitis in the era of minimally invasive medicine. Copyright Ó 2013, Society of Gastrointestinal Intervention. Published by Elsevier. All rights reserved. Keywords: Acute cholecystitis, Interventional radiology, Percutaneous cholecystostomy
Introduction Acute cholecystitis (AC) is one of the most common gastrointestinal diseases encountered in the emergency department.1 Cholecystectomy (CCY) is regarded as the standard treatment for AC patients.2–7 The major role of percutaneous transhepatic gallbladder drainage (PTGBD) is temporary stabilization of the patient’s acute debilitating condition prior to CCY.8–12 However, PTGBD can be a permanent treatment for patients who are not candidates for surgery (Figs. 1–3). Moreover, in some patients, there may be a possibility of undergoing unnecessary surgery when it can be managed alternatively via conservative management with or without PTGBD. In this article, the author restates the role of PTGBD in patients with AC in the era of minimally invasive medicine.
studies, this study lacks good randomization between two comparative groups. PTGBD was performed for more debilitated and high-risk patients than those who underwent CCY. Kortram et al,
Controversies Traditionally, patients are prepared to proceed to cholecystectomy whenever they are ready. However, there is some controversy as to which patients PTGBD is indicated. Another controversy is whether CCY is mandatory after PTGBD because CCY is not free of complications.13 As for the first controversy, there is as yet no clear evidence for which is the best treatment for AC patients. Abi-Haidar et al compared the outcomes of PTGBD with those of CCY for AC patients and concluded that PTGBD should be reserved only for patients with prohibitive risks for surgery due to its high association with higher morbidity rates.14 However, as are with many other comparative
Fig. 1. Computed tomography scan of a 75-year-old woman with acute cholecystitis admitted to the emergency room. The gallbladder was distended with wall thickening (arrowheads) and a stone (black arrow). Another stone was also noticed in the common bile duct (white arrow).
Department of Radiology, University of Ulsan College of Medicine, Songpa-Gu, Seoul, South Korea Received 29 March 2013; Accepted 31 March 2013 * Department of Radiology, University of Ulsan College of Medicine, 388-1 Poongnap-2-dong, Songpa-gu, Seoul 138-736, South Korea. E-mail address: [email protected] (H.-K. Yoon).
2213-1795/$ – see front matter Copyright Ó 2013, Society of Gastrointestinal Intervention. Published by Elsevier. All rights reserved. http://dx.doi.org/10.1016/j.gii.2013.04.002
48
Gastrointestinal Intervention 2013 2(1), 47–49
Fig. 2. Percutaneous transhepatic gallbladder drainage was performed. The common bile duct stone was removed by an endoscopic approach (not shown here). Percutaneous transhepatic gallbladder drainage tube was removed 12 days later because the patient did not want cholecystostomy.
however, conducted a randomized controlled study between two groups of high-risk AC patients.15 According to this, there was a consensus that patients with an Acute Physiology and Chronic Health Evaluation (APACHE)-II score <7 should undergo emergency laparoscopic CCY, whereas patients with a score >14 would be better to undergo PTGBD. In patients with an APACHE II score 7–14, opinions differ and no consensus was reached regarding which treatment was better. According to Kortram et al, PTGBD has obviated the need for emergency operations in high-risk patients, and has helped to save time for patients conditioning for elective surgery and general anesthesia. As for the second controversy, once PTGBD is performed, an interval CCY seems to be mandatory, and the only exceptions are the selected high-risk patients with acalculous AC in whom the PTGBD can be considered as a definitive treatment. For this matter, there has not been a well-designed randomized controlled study as to whether
Fig. 3. A 10-year follow-up computed tomography scan showed normalization of gallbladder wall thickening (arrowheads) with silent gallstone (black arrow) in situ. The patient had been free of recurrent cholecystitis symptoms for 10 years.
the PTGBD group is inferior to the delayed CCY group in longer-term mortality and morbidity. In some patients, PTGBD may obviate unnecessary CCY if patients are left well without significant complications. The cost-effectiveness evaluation for the two groups should also be performed in order to conclude whether or not CCY must be followed after stabilization of the AC patient’s general conditions. McGillicuddy et al analyzed the data of 185 AC patients without operative treatment.16 Out of 67 PTGBD patients, 44 had subsequent CCY with a complication rate of 23%. No deaths or major complications occurred among those with recurrent AC. Therefore, they concluded that medical management with or without PTGBD may be appropriate for select patients. Interval CCY is needed only for recurrent AC.
Patient with acute cholecystitis
Surgical candidate
Nonsurgical candidate
Cholecystectomy
Medical management
Clinical improvement
+ Delayed cholecystectomy in selected patients
Percutaneous transhetic gallbladder Drainage
+ Surgical candidate
Permanent PTGBD until patient’s stabilization Fig. 4. Suggested treatment flow chart for acute cholecystitis patients from an interventional radiologist’s viewpoint.
Hyun-Ki Yoon / Acute cholecystitis
Rimkus and Kalff followed acalculous AC patients and according to their observations, more than 90% of the patients treated by PTGBD showed no recurrence of symptoms during a period of more than 1 year.17 Thus, it is unclear as to whether delayed CCY is still justified for these patients who were previously treated by PTGBD. By contrast, Morse et al evaluated the clinical course and outcomes of critically ill AC patients (n ¼ 50) who underwent PTGBD and subsequent CCY. They concluded that the removal of the PTGBD tube without subsequent CCY is associated with a high recurrence of AC and devastating consequences.8 However, it cannot be concluded that CCY must be performed for AC patients who have been stabilized in general conditions after PTGBD. In some patients, such as hemodialysis patients, patients in intensive care, and pregnant women, CCY seems to be unnecessary after PTGBD.18 Recommendations from an interventional radiologist’s viewpoint Laparoscopic CCY may be the standard treatment for AC whenever indicated. PTGBD may be indicated for high-risk patients for surgery. However, the role of medical treatment with or without PTGBD should not be ignored. When AC patients are stabilized in general conditions, delayed CCY is not mandatory; selected patients can be managed cautiously without surgery. A possible schematic treatment is shown in Fig. 4, reflecting the viewpoint of an interventional radiologist. A well-designed prospective randomized trial is warranted comparing between the medical treatment group with or without PTGBD and the CCY group for proper management guidelines of AC patients. Conflict of interest The author has no financial disclosure of conflict of interest. References 1. Strasberg SM. Clinical practice. Acute calculous cholecystitis. N Engl J Med. 2008;358:2804–11.
49
2. Duncan CB, Riall TS. Evidence-based current surgical practice: calculous gallbladder disease. J Gastrointest Surg. 2012;16:2011–25. 3. Navez B, Ungureanu F, Michiels M, Claeys D, Muysoms F, Hubert C, et al. Surgical management of acute cholecystitis: results of a 2-year prospective multicenter survey in Belgium. Surg Endosc. 2012;26:2436–45. 4. Suter M, Meyer AA. 10-year experience with the use of laparoscopic cholecystectomy for acute cholecystitis: is it safe? Surg Endosc. 2001;15:1187–92. 5. Solej M, Martino V, Mao P, Enrico S, Rosa R, Fornari M, et al. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Minerva Chir. 2012;67:381–7. 6. Skouras C, Jarral O, Deshpande R, Zografos G, Habib N, Zacharakis E. Is early laparoscopic cholecystectomy for acute cholecystitis preferable to delayed surgery?: best evidence topic (BET). Int J Surg. 2012;10:250–8. 7. Brooks KR, Scarborough JE, Vaslef SN, Shapiro ML. No need to wait: an analysis of the timing of cholecystectomy during admission for acute cholecystitis using the American College of Surgeons National Surgical Quality Improvement Program database. J Trauma Acute Care Surg. 2013;74:167–73. 173–4. 8. Morse BC, Smith JB, Lawdahl RB, Roettger RH. Management of acute cholecystitis in critically ill patients: contemporary role for cholecystostomy and subsequent cholecystectomy. Am Surg. 2010;76:708–12. 9. Boggi U, Di Candio G, Campatelli A, Oleggini M, Pietrabissa A, Filipponi F, et al. Percutaneous cholecystostomy for acute cholecystitis in critically ill patients. Hepatogastroenterology. 1999;46:121–5. 10. Nasim S, Khan S, Alvi R, Chaudhary M. Emerging indications for percutaneous cholecystostomy for the management of acute cholecystitisda retrospective review. Int J Surg. 2011;9:456–9. 11. McKay A, Abulfaraj M, Lipschitz J. Short- and long-term outcomes following percutaneous cholecystostomy for acute cholecystitis in high-risk patients. Surg Endosc. 2012;26:1343–51. 12. Melloul E, Denys A, Demartines N, Calmes JM, Schäfer M. Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter? World J Surg. 2011;35: 826–33. 13. Strasberg SM, Helton WS. An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy. HPB (Oxford). 2011;13:1–14. 14. Abi-Haidar Y, Sanchez V, Williams SA, Itani KM. Revisiting percutaneous cholecystostomy for acute cholecystitis based on a 10-year experience. Arch Surg. 2012;147:416–22. 15. Kortram K, van Ramshorst B, Bollen TL, Besselink MG, Gouma DJ, Karsten T, et al. Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy (CHOCOLATE trial): study protocol for a randomized controlled trial. Trials. 2012;13:7. 16. McGillicuddy EA, Schuster KM, Barre K, Suarez L, Hall MR, Kaml GJ, et al. Nonoperative management of acute cholecystitis in the elderly. Br J Surg. 2012; 99(9):1254–61. 17. Rimkus C, Kalff JC. The intensive care gallbladder as shock organ: symptoms and therapy. Chirurg. 2013;84:197–201. [in German] 18. Little MW, Briggs JH, Tapping CR, Bratby MJ, Anthony S, Phillips-Hughes J, et al. Percutaneous cholecystostomy: The radiologist’s role in treating acute cholecystitis. Clin Radiol. 2013. http://dx.doi.org/10.1016/j.crad.2013.01.017.
Contents lists available at SciVerse ScienceDirect
Gastrointestinal Intervention journal homepage: www.gi-intervention.org
Review Article
Acute cholecystitis: We can drain it! Hyun-Ki Yoon* a b s t r a c t Laparoscopic cholecystectomy has recently been accepted as the standard treatment for acute cholecystitis patients. The major role of percutaneous transhepatic gallbladder drainage has been temporarily stabilizing the patient’s acute debilitating condition prior to cholecystectomy. However, there have not been any evidence-based treatment guidelines for acute cholecystitis patients. In this article, the author restates the role of percutaneous transhepatic gallbladder drainage in patients with acute cholecystitis in the era of minimally invasive medicine. Copyright Ó 2013, Society of Gastrointestinal Intervention. Published by Elsevier. All rights reserved. Keywords: Acute cholecystitis, Interventional radiology, Percutaneous cholecystostomy
Introduction Acute cholecystitis (AC) is one of the most common gastrointestinal diseases encountered in the emergency department.1 Cholecystectomy (CCY) is regarded as the standard treatment for AC patients.2–7 The major role of percutaneous transhepatic gallbladder drainage (PTGBD) is temporary stabilization of the patient’s acute debilitating condition prior to CCY.8–12 However, PTGBD can be a permanent treatment for patients who are not candidates for surgery (Figs. 1–3). Moreover, in some patients, there may be a possibility of undergoing unnecessary surgery when it can be managed alternatively via conservative management with or without PTGBD. In this article, the author restates the role of PTGBD in patients with AC in the era of minimally invasive medicine.
studies, this study lacks good randomization between two comparative groups. PTGBD was performed for more debilitated and high-risk patients than those who underwent CCY. Kortram et al,
Controversies Traditionally, patients are prepared to proceed to cholecystectomy whenever they are ready. However, there is some controversy as to which patients PTGBD is indicated. Another controversy is whether CCY is mandatory after PTGBD because CCY is not free of complications.13 As for the first controversy, there is as yet no clear evidence for which is the best treatment for AC patients. Abi-Haidar et al compared the outcomes of PTGBD with those of CCY for AC patients and concluded that PTGBD should be reserved only for patients with prohibitive risks for surgery due to its high association with higher morbidity rates.14 However, as are with many other comparative
Fig. 1. Computed tomography scan of a 75-year-old woman with acute cholecystitis admitted to the emergency room. The gallbladder was distended with wall thickening (arrowheads) and a stone (black arrow). Another stone was also noticed in the common bile duct (white arrow).
Department of Radiology, University of Ulsan College of Medicine, Songpa-Gu, Seoul, South Korea Received 29 March 2013; Accepted 31 March 2013 * Department of Radiology, University of Ulsan College of Medicine, 388-1 Poongnap-2-dong, Songpa-gu, Seoul 138-736, South Korea. E-mail address: [email protected] (H.-K. Yoon).
2213-1795/$ – see front matter Copyright Ó 2013, Society of Gastrointestinal Intervention. Published by Elsevier. All rights reserved. http://dx.doi.org/10.1016/j.gii.2013.04.002
48
Gastrointestinal Intervention 2013 2(1), 47–49
Fig. 2. Percutaneous transhepatic gallbladder drainage was performed. The common bile duct stone was removed by an endoscopic approach (not shown here). Percutaneous transhepatic gallbladder drainage tube was removed 12 days later because the patient did not want cholecystostomy.
however, conducted a randomized controlled study between two groups of high-risk AC patients.15 According to this, there was a consensus that patients with an Acute Physiology and Chronic Health Evaluation (APACHE)-II score <7 should undergo emergency laparoscopic CCY, whereas patients with a score >14 would be better to undergo PTGBD. In patients with an APACHE II score 7–14, opinions differ and no consensus was reached regarding which treatment was better. According to Kortram et al, PTGBD has obviated the need for emergency operations in high-risk patients, and has helped to save time for patients conditioning for elective surgery and general anesthesia. As for the second controversy, once PTGBD is performed, an interval CCY seems to be mandatory, and the only exceptions are the selected high-risk patients with acalculous AC in whom the PTGBD can be considered as a definitive treatment. For this matter, there has not been a well-designed randomized controlled study as to whether
Fig. 3. A 10-year follow-up computed tomography scan showed normalization of gallbladder wall thickening (arrowheads) with silent gallstone (black arrow) in situ. The patient had been free of recurrent cholecystitis symptoms for 10 years.
the PTGBD group is inferior to the delayed CCY group in longer-term mortality and morbidity. In some patients, PTGBD may obviate unnecessary CCY if patients are left well without significant complications. The cost-effectiveness evaluation for the two groups should also be performed in order to conclude whether or not CCY must be followed after stabilization of the AC patient’s general conditions. McGillicuddy et al analyzed the data of 185 AC patients without operative treatment.16 Out of 67 PTGBD patients, 44 had subsequent CCY with a complication rate of 23%. No deaths or major complications occurred among those with recurrent AC. Therefore, they concluded that medical management with or without PTGBD may be appropriate for select patients. Interval CCY is needed only for recurrent AC.
Patient with acute cholecystitis
Surgical candidate
Nonsurgical candidate
Cholecystectomy
Medical management
Clinical improvement
+ Delayed cholecystectomy in selected patients
Percutaneous transhetic gallbladder Drainage
+ Surgical candidate
Permanent PTGBD until patient’s stabilization Fig. 4. Suggested treatment flow chart for acute cholecystitis patients from an interventional radiologist’s viewpoint.
Hyun-Ki Yoon / Acute cholecystitis
Rimkus and Kalff followed acalculous AC patients and according to their observations, more than 90% of the patients treated by PTGBD showed no recurrence of symptoms during a period of more than 1 year.17 Thus, it is unclear as to whether delayed CCY is still justified for these patients who were previously treated by PTGBD. By contrast, Morse et al evaluated the clinical course and outcomes of critically ill AC patients (n ¼ 50) who underwent PTGBD and subsequent CCY. They concluded that the removal of the PTGBD tube without subsequent CCY is associated with a high recurrence of AC and devastating consequences.8 However, it cannot be concluded that CCY must be performed for AC patients who have been stabilized in general conditions after PTGBD. In some patients, such as hemodialysis patients, patients in intensive care, and pregnant women, CCY seems to be unnecessary after PTGBD.18 Recommendations from an interventional radiologist’s viewpoint Laparoscopic CCY may be the standard treatment for AC whenever indicated. PTGBD may be indicated for high-risk patients for surgery. However, the role of medical treatment with or without PTGBD should not be ignored. When AC patients are stabilized in general conditions, delayed CCY is not mandatory; selected patients can be managed cautiously without surgery. A possible schematic treatment is shown in Fig. 4, reflecting the viewpoint of an interventional radiologist. A well-designed prospective randomized trial is warranted comparing between the medical treatment group with or without PTGBD and the CCY group for proper management guidelines of AC patients. Conflict of interest The author has no financial disclosure of conflict of interest. References 1. Strasberg SM. Clinical practice. Acute calculous cholecystitis. N Engl J Med. 2008;358:2804–11.
49
2. Duncan CB, Riall TS. Evidence-based current surgical practice: calculous gallbladder disease. J Gastrointest Surg. 2012;16:2011–25. 3. Navez B, Ungureanu F, Michiels M, Claeys D, Muysoms F, Hubert C, et al. Surgical management of acute cholecystitis: results of a 2-year prospective multicenter survey in Belgium. Surg Endosc. 2012;26:2436–45. 4. Suter M, Meyer AA. 10-year experience with the use of laparoscopic cholecystectomy for acute cholecystitis: is it safe? Surg Endosc. 2001;15:1187–92. 5. Solej M, Martino V, Mao P, Enrico S, Rosa R, Fornari M, et al. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Minerva Chir. 2012;67:381–7. 6. Skouras C, Jarral O, Deshpande R, Zografos G, Habib N, Zacharakis E. Is early laparoscopic cholecystectomy for acute cholecystitis preferable to delayed surgery?: best evidence topic (BET). Int J Surg. 2012;10:250–8. 7. Brooks KR, Scarborough JE, Vaslef SN, Shapiro ML. No need to wait: an analysis of the timing of cholecystectomy during admission for acute cholecystitis using the American College of Surgeons National Surgical Quality Improvement Program database. J Trauma Acute Care Surg. 2013;74:167–73. 173–4. 8. Morse BC, Smith JB, Lawdahl RB, Roettger RH. Management of acute cholecystitis in critically ill patients: contemporary role for cholecystostomy and subsequent cholecystectomy. Am Surg. 2010;76:708–12. 9. Boggi U, Di Candio G, Campatelli A, Oleggini M, Pietrabissa A, Filipponi F, et al. Percutaneous cholecystostomy for acute cholecystitis in critically ill patients. Hepatogastroenterology. 1999;46:121–5. 10. Nasim S, Khan S, Alvi R, Chaudhary M. Emerging indications for percutaneous cholecystostomy for the management of acute cholecystitisda retrospective review. Int J Surg. 2011;9:456–9. 11. McKay A, Abulfaraj M, Lipschitz J. Short- and long-term outcomes following percutaneous cholecystostomy for acute cholecystitis in high-risk patients. Surg Endosc. 2012;26:1343–51. 12. Melloul E, Denys A, Demartines N, Calmes JM, Schäfer M. Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter? World J Surg. 2011;35: 826–33. 13. Strasberg SM, Helton WS. An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy. HPB (Oxford). 2011;13:1–14. 14. Abi-Haidar Y, Sanchez V, Williams SA, Itani KM. Revisiting percutaneous cholecystostomy for acute cholecystitis based on a 10-year experience. Arch Surg. 2012;147:416–22. 15. Kortram K, van Ramshorst B, Bollen TL, Besselink MG, Gouma DJ, Karsten T, et al. Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy (CHOCOLATE trial): study protocol for a randomized controlled trial. Trials. 2012;13:7. 16. McGillicuddy EA, Schuster KM, Barre K, Suarez L, Hall MR, Kaml GJ, et al. Nonoperative management of acute cholecystitis in the elderly. Br J Surg. 2012; 99(9):1254–61. 17. Rimkus C, Kalff JC. The intensive care gallbladder as shock organ: symptoms and therapy. Chirurg. 2013;84:197–201. [in German] 18. Little MW, Briggs JH, Tapping CR, Bratby MJ, Anthony S, Phillips-Hughes J, et al. Percutaneous cholecystostomy: The radiologist’s role in treating acute cholecystitis. Clin Radiol. 2013. http://dx.doi.org/10.1016/j.crad.2013.01.017.