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Cholecystostomy: A place in modern biliary surgery?
Cholecystostomy:
A Place in Modern Biliary Surgery?
John C. Skillings, MD, Rochester, Claudia Kumai, PAC, Rochester,
New York New York
J. Raymond Hinshaw, MD, FACS, Rochester,
New York
Most surgeons consider cholecystostomy inferior to cholecystectomy in the treatment of diseases of the biliary tract and use it only for limited and specific indications. However, opinions differ on the value of this procedure in certain circumstances. Cholecystoszomy has been advocated when the patient is considered too ill to survive cholecystectomy, when the patient’s condition deteriorates or when technical difficulties are encountered during the operation. Generally, those deemed too ill for cholecystectomy are elderly and have severe cardiac, pulmonary or renal insufficiency or are poorly controlled, insulindependent diabetic patients with acute, gangrenous or perforated cholecystitis. It is in this patient group that many surgeons believe cholecystostomy can be lifesaving. Mortality rates higher than 20 percent have been reported for cholecystostomy performed in the presence of an acute biliary inflammatory process. On the contrary, our experience indicates that cholecystostomy, when properly employed, can be performed with relative safety in these high risk patients and has a small but definite role in the surgical management of biliary tract disease. Cholecystostomies performed during the past 10 years, from 1967 to 1977, were reviewed in an attempt to better define the indications for cholecystostomy in the surgical therapy of biliary tract disease. Material
and Methods
One hundred fifteen patients underwent cholecystostomy during the 10 year period. Of these, 63 were men and 52 were women (Figure 1). The patients were classified in two groups on the basis of their clinical presentation. Group I consisted of 88 patients with symptoms of acute choleFrom the Department of Surgery, University of Rochester School of Medicine and Dentistry, and the Department of Surgery, Rochester General Hospital, Rochester, New York. Reprint requests should be addressed to J. Raymond Hinshaw. MD, Department of Surgery, Rochester General Hospital, 1425 Portland Avenue, Rochester, New York 1462 1.
Volume 139, June 1980
cystitis, whereas the remaining 27 (group II) had laparotomy for various abdominal conditions but also underwent cholecystostomy as part of the procedure (Figure 2). The age range was 16 to 93 years for both clinical groups; 68 percent of group I patients and 72 percent of group II patients were aged 60 to 90 years. In group I, empyema was encountered in 15 patients, perforation of the gallbladder in 9 and hydrops of the gallbladder in 5. In the majority of patients in group II, suspected malignancy, pancreatitis or trauma was the main reason for surgery. Laboratory data: Leukocytosis of greater than lO,OOO/mm” was seen in 75 of the 88 patients with acute cholecystitis and in 23 of 27 patients in the other group. Elevations in the total serum bilirubin greater than 1.2 mg/lOO ml occurred less frequently, being seen in 46 of 88 patients in group I and in 15 of 27 in group II. Cultures of the gallbladder were infrequently performed in this series, but most patients received empiric antibiotic coverage during or after surgery, or both (Table I). Of the 88 patients with acute symptoms and signs, 74 received some type of antibiotic coverage, whereas 25 of 27 patients in group II received antibiotic support. In the majority of cases the antibiotics employed included either ampicillin or a cephalosporin and in the more severely debilitated patients an aminoglycoside also. Complications: Nonfatal complications occurred in 48 (42 percent) of the patients in this series, that is, in 33 of 88 patients (37 percent) in group I and in 15 of 25 patients (56 percent) in group II (Table II). The most common complication, retained gallbladder or common bile duct stones, occurred in 29 patients, whereas 21 patients had infections related to the wound or operative site. Of the patients presenting with acute symptoms in whom postoperative wound sepsis developed, 3 had no antibiotic coverage in the perioperative period, whereas in 11 antibiotic therapy was begun postoperatively. In only 6 of the 49 patients with antibiotic therapy begun preoperatively and continued postoperatively did infections develop. Conversely, in only one patient in the nonacute patient population did a wound infection develop. Other complications directly related to surgery included hemorrhage along the drain tract [2], pneumonia [3] and persistent biliarj fistula [4].
665
Skillings et al
MLE 30 25
=n
FDHLE
- 9,
TOTAL
=
n
n 15 1* 5
Figure 7. Age and distribution by sex of patients who underwent cholecystosfomy between 7967 and 1977.
3 L
m-25
Figure 2. Proportion of patients in the f wo clinical groups in each decade of life.
TABLE
I
TABLE II
Antibiotic Therapy No. of Patients
I
Antibiotic Therapy
Group
Group II
Preoperative only Pre- and postoperative Postoperative only None
3 49 22 14
1 11 12 3
Total
88
27
Results Mortality: Eighteen patients died after operation or reoperation. Eight of these deaths occurred in patients having cholecystostomy for acute cholecystitis, whereas 10 of the deaths occurred in group II patients (Table III). In group I, three deaths occurred at the time of reexploration for definitive cholecystectomy more than 1 month after cholecystostomy. Elimination of these three deaths from consideration results in a mortality of 6 percent (5 of 88) for cholecystostomy performed for acute inflammatory disease of the biliary tract. All five patients had gram-negative septicemia, documented by blood culture, whereas the three patients who died after a second procedure died from a combination of problems including infection, cardiac and respiratory decompensation and hepatic failure. This frequent combination of mortality after cholecystostomy and septic shock was also seen by Bulow et al [I]. 866
In-Hospital Complications
Comolication
Grow I
Grow II
Total
Wound infection lntraabdominal abscess Retained stone Gallbladder Common bile duct Hemorrhage Pneumonia Fistula Pulmonary embolus
13 7
1 0
14 7
11 14 1 2 3 1
3 1 1 1 1 0
14 15 2 3 4 1
Total
52
8
60
Conversely, in the nonacute group of patients, the mortality was 10 of 27 patients or 37 percent. These deaths were largely the result of incurable malignancies necessitating palliative cholecystostomy or were secondary to severe associated multisystem disease. Follow-up: Follow-up data through at least 1 year were available in 97 of the 115 patients in the study. Of these, 18 have died, 45 have undergone definitive cholecystectomy, and 34 have remained asymptomatic without further operative intervention. Of those having further surgery, 29 had retained calculi in the gallbladder or common duct as one indication for the procedure, whereas the remaining patients were asymptomatic at the time of elective cholecystectomy. The Amerlcan Journal of Surgery
Cholecystostomy
procedures are at times necessary in the treatment of appendiceal abscesses and perforated diverticulitis, so too in comparable biliary tract disease cholecystostomy finds its niche. The procedure can usually be performed rapidly through a small incision with the patient under light general or local anes-
Comments Although cholecystostomy accounts for less than 5 percent of operations on the biliary tract at our hospital, it remains a favored alternative to cholecystectomy in selected circumstances. Just as staged
TABLE Patient NC’.
--
Ill
Mortality _____ Age (yr) & Sex
Cause
Time
Other Diseases Group
57 M
>30 days
E. coli sepsis at reoperation
74 M
Acute
57 M
Acute
E. coli/ Klebsiella E. coli sepsis
78 M
Acute
E. coli sepsis
5
55 F
Sepsis/Klebsiella
6
69 M
>30 days >a0 days
7
80 F
Acute
8
72 M
Acute
1
E. coli sepsis, respiratory failure E. coli sepsis, carcinomatosis Sepsis
Antibiotics Postoperative Preoperative
I
Carcinoma of the lung cirrhosis of the liver with portal hypertension ASCVD
Gentamicin; ampicillin
Ampicillin
High blood pressure, carcinoma of the lung ASCVD perforated gallbladder with peritonitis Carcinoma of the colon, retained stone Diabetes mellitus, ASCVD, high blood pressure, COPD Carcinoma of the colon
Clindamycin
Kanamycin
Ampicillin
Kanamycin and KeflinQ
Penicillin
Penicillin
COPD, ASCVD. peritonitis
Ampicillin
Chloramphenicol
Group II _ 1
82 F
Acute
CVA
2
57 M
3
86 F
>30 days Acute
Carcinoma of the pancreas Myocardial infarction
4
58 M
Acute
5
78 M
6
65 M
>30 days Acute
7
73 F
Acute
8
36 F
Acute
9
67 M
Acute
10
86 M
Acute
Ruptured mycotic abdominal aortic aneurysm Carcinoma of the pancreas Carcinoma of the common bile duct Pulmonary embolus Hemorrhagic pancreatitis Colonic perforation, sepsis Carcinoma of the gallbladder
RXVD = arteriosclerotic E. coli = Escherichia coli.
Volume 139, June 1980
cardiovascular
ASCVD, diabetes mellitus, COPD
Kanamycin
Gentamicin ampicillin ASCVD, COPD, carcinoma of the pancreas with metastasis to liver Salmonella sepsis
COPD, ASCVD Diabetes mellitus
Keflin
Keflin
Keflin
Keflin Ampicillin
Diabetes mellitus Chronic asthma, bronchitis Hemophilia
Chloramphenicol
Chloramphenicol Keflin
ASCVD, diabetes mellitus, COPD
disease; COPD = chronic obstructive
pulmonary disease; CVA = cerebrovascular
accident;
867
Skillingset al
thesia, thus minimizing operative insult to precariously ill or toxic patients. In other situations, it can provide decompression of the biliary tree and prevent the need for extensive dissection through tissue planes obliterated by the inflammatory process, thus protecting the patient from potential biliary complications when the primary operative procedure involves another organ system. In the last 2 decades many surgeons have reaffirmed the value of cholecystostomy. Although labeled an “unwanted stepchild” in the family of surgical procedures, Ross and Dunphy [2] along with Glenn [3], Sparkman [4], Gagic and Frey [5], Havard and Parry [6] and Welch and Malt [ 71 emphasize its importance in selected circumstances. The multiple factors that often enter into the decision to perform cholecystostomy include intraoperative deterioration of the patient’s condition, technical problems and associated preexisting conditions such as cardiovascular, renal, hepatic or pulmonary diseases, diabetes mellitus or gram-negative septicemia. Physiologic age is an important secondary factor in such a decision. The advantages of this procedure are not reflected in reported mortality rates. Compared with the generally accepted mortality rate of less than 6 percent for emergency cholecystectomy, the mortality rate for cholecystostomy has been reported to be 20 to 25 percent by Welch and Malt [ 71, Field and Jones [S] and Gingrich et al [9] and as high as 30 percent by Costello [IO]. In general, this high mortality reflects the condition of the patients who are often poor risks for any operation. The overall mortality in this series (18 of 115 patients) was 15.6 percent, the majority of deaths occurring in the nonacute patient population (10 of 27, or 37 percent), whereas the mortality for cholecystostomy in the presence of acute cholecystitis was 5 of 88 or 5.7 percent. The reason for our relatively low mortality in patients with an acute condition is unclear, although a willingness to perform cholecystostomy as a primary temporizing procedure rather than after extensive dissection in a futile attempt at cholecystectomy may have improved our results. The average age and distribution of our patient population appears similar to those reported by others. Another factor contributing to the low mortality in our series may be the beneficial use of antibiotics liberally pre-, intra- and postoperatively in the acutely ill patients, thus possibly converting a fatal complication to a nonfatal one. Technique may also affect survival statistics. If cholecystostomy is performed for acute cholecystitis and if no clear bile flows through the cystic duct, the surgeon must obtain radiographic evidence of a
066
patent cystic duct. If not, the common bile duct must be diseased. In the past patients with acute ascending cholangitis may have been treated without truly adequate drainage of the biliary system, thus resulting in a higher mortality. Of the five patients with acute cholecystitis who died, all had irreversible gram-negative shock, even with an adequately functioning cholecystostomy. The higher mortality in our nonacute patients generally reflects the nature of the patients’ diseases. Five had carcinoma, three had severe cardiovascular disease, one had hemorrhagic pancreatitis, and one had a massive pulmonary embolus 3 days postoperatively. The importance of postcholecystostomy cholangiography was emphasized by Welch and Malt [7] and is demonstrated again in our series. In 25 patients in group I and 14 in group II, retained stones in the gallbladder or common bile duct were demonstrated by cholangiography. Subsequent cholecystectomy is recommended for patients with retained stones, but the question of whether cholecystectomy is indicated when the initial problem is alleviated by cholecystostomy and there is no retained stone has been posed for years. Hays and Glenn [II] thought that the likelihood of symptomatic biliary tract disease developing more than 2 years after cholecystostomy was greater than 50 percent. Norrby and Schijnebeck [12] reported an 83 percent incidence of recurrent calculi after cholecystostomy in patients followed up for 15 years. Conversely, Ross and Dunphy [2] estimated that 50 percent of patients will remain asymptomatic after cholecystostomy, whereas Field and Jones [8] found that 80 percent of their postcholecystostomy patients remained asymptomatic 1 to 12 years after surgery. In our series 45 patients underwent elective cholecystectomy in the 1st year of follow-up, whereas 34 were asymptomatic without further surgery. The 29 patients with retained stones may eventually have become symptomatic, but the course of the 16 without stones who underwent planned, interval cholecystectomy for asymptomatic disease can only be surmised. If they were all to develop symptoms, our recurrence rate would be 56.9 percent, similar to that of Hays and Glenn [II], whereas if these patients remained asymptomatic, our incidence of recurrent disease becomes similar to that of Field and Jones [8], 36.7 percent. Attempting to define a group of patients likely to have recurrent symptoms, Condon and Nyhus [13] divided postcholecystostomy patients into two groups: those who become symptomatic and those who do not. Their data revealed that if cholecystitis develops postoperatively, symptoms will most likely
The American Journal of Surgery
Cholecystostomy
occur within the 1st postoperative year. Welch and Malt [ 71 also reported that in more than 75 percent of their patients, recurrent disease developed within the 1st year after cholecystostomy. They noted that recurrent disease develops in fewer than 12 percent of patients with normal postoperative cholangiograms, whereas recurrent symptoms develop in up to 80 percent of those with retained stones or abnclrmal emptying of the common bile duct. On the basis of our series we believe that t.he patient who has abnormal results on cholangiography sl:ouId undergo prompt cholecystectomy, conditions permitting, even though asymptomatic, whereas the asymptomatic, poor risk patient with a normal appearing ductal syst.em demonstrated by cholangiography should not undergo reoperation because the chance of cholecystitis developing, particularly after 1 year, is minimal. In none of the 34 patients without retained stones followed up more than 1 year has acute cholecystitis or symptoms necessitating an operation developed. Summary Cholecystostomy retains a place in the general surgical armamentarium. In this series of 115 patients undergoing cholecystostomy between 1967 and 1977,68 percent had acute cholecystitis, whereas in tb e remaining patients biliary drainage was undertaken as part of another procedure. The in-hospital mortality rate was 6 percent for the group with acute cholecystitis and 37 percent for the other patients. Forty-five patients subsequently had elective cholecystectomy, 29 of these for radiographically docu-
Volume
139, June 1980
mented retained calculi. Thirty-four patients without retained calculi remained asymptomatic for more than 1 year. On the basis of this experience and the literature cited, we recommend that subsequent to cholecystostomy, cholecystectomy be performed if the patient is in good general health and has a long life expectancy. Conversely, in the aged, ill patient without evidence of retained stones, cholecystostomy may be a lifesaving and curative procedure and the only one needed.
References 1. Bulow S, Kronburg 0, Lund-Kristensen J. Reappraisal of surgery for suppurative cholecystitis. Arch Surg 1977;112:262. 2. Ross RP, Dunphy JE. Studies in acute cholecystitis. II. N Engl J Med 1950;242:359. 3. Glenn F. Surgical treatment of acute cholecystitis. Surg Gynecol Obstet 1950;90:643. 4. Sparkman RS. Planned cholecystostomy. Ann Surg 1959; 149:746. 5. Gagic N, Frey CF. The results of cholecystostomy for the treatment of acute cholecystitis. Surg Gynecol Obstet 1975;140:255. 6. Havard C, Parry D. Cholecystostomy. Br J Surg 1976;63: 631. 7. Welch JP, Malt RA. Outcome of cholecystostomy. Surg Gynecol Obstet 1972;135:717. a. Field RJ Jr, Jones WR. Cholecystostomy. South Med J 1970; 63: 1034. 9. Gingrich RA, Awe WC, Boyden AM, Peterson CG. Acute cholecystitis. Am J Surg 1966;116:310. 10. Costello C. Cholecystostomy in modern surgery. Am Surg 1956;22:1079. 11. Hays DM, Glenn F. The fate of the cholecystostomy patient. J Am Geriatr Sot 1955;3:21. 12. Norrby S, Schdnebeck J. Long term results with cholecystolithotomy. Acta Chir Stand 1970; 136:7 Il. 13. Condon RE, Nyhus LM. Cholecystostomy in the aged. Am J Surg 1960;100:544.
669
A Place in Modern Biliary Surgery?
John C. Skillings, MD, Rochester, Claudia Kumai, PAC, Rochester,
New York New York
J. Raymond Hinshaw, MD, FACS, Rochester,
New York
Most surgeons consider cholecystostomy inferior to cholecystectomy in the treatment of diseases of the biliary tract and use it only for limited and specific indications. However, opinions differ on the value of this procedure in certain circumstances. Cholecystoszomy has been advocated when the patient is considered too ill to survive cholecystectomy, when the patient’s condition deteriorates or when technical difficulties are encountered during the operation. Generally, those deemed too ill for cholecystectomy are elderly and have severe cardiac, pulmonary or renal insufficiency or are poorly controlled, insulindependent diabetic patients with acute, gangrenous or perforated cholecystitis. It is in this patient group that many surgeons believe cholecystostomy can be lifesaving. Mortality rates higher than 20 percent have been reported for cholecystostomy performed in the presence of an acute biliary inflammatory process. On the contrary, our experience indicates that cholecystostomy, when properly employed, can be performed with relative safety in these high risk patients and has a small but definite role in the surgical management of biliary tract disease. Cholecystostomies performed during the past 10 years, from 1967 to 1977, were reviewed in an attempt to better define the indications for cholecystostomy in the surgical therapy of biliary tract disease. Material
and Methods
One hundred fifteen patients underwent cholecystostomy during the 10 year period. Of these, 63 were men and 52 were women (Figure 1). The patients were classified in two groups on the basis of their clinical presentation. Group I consisted of 88 patients with symptoms of acute choleFrom the Department of Surgery, University of Rochester School of Medicine and Dentistry, and the Department of Surgery, Rochester General Hospital, Rochester, New York. Reprint requests should be addressed to J. Raymond Hinshaw. MD, Department of Surgery, Rochester General Hospital, 1425 Portland Avenue, Rochester, New York 1462 1.
Volume 139, June 1980
cystitis, whereas the remaining 27 (group II) had laparotomy for various abdominal conditions but also underwent cholecystostomy as part of the procedure (Figure 2). The age range was 16 to 93 years for both clinical groups; 68 percent of group I patients and 72 percent of group II patients were aged 60 to 90 years. In group I, empyema was encountered in 15 patients, perforation of the gallbladder in 9 and hydrops of the gallbladder in 5. In the majority of patients in group II, suspected malignancy, pancreatitis or trauma was the main reason for surgery. Laboratory data: Leukocytosis of greater than lO,OOO/mm” was seen in 75 of the 88 patients with acute cholecystitis and in 23 of 27 patients in the other group. Elevations in the total serum bilirubin greater than 1.2 mg/lOO ml occurred less frequently, being seen in 46 of 88 patients in group I and in 15 of 27 in group II. Cultures of the gallbladder were infrequently performed in this series, but most patients received empiric antibiotic coverage during or after surgery, or both (Table I). Of the 88 patients with acute symptoms and signs, 74 received some type of antibiotic coverage, whereas 25 of 27 patients in group II received antibiotic support. In the majority of cases the antibiotics employed included either ampicillin or a cephalosporin and in the more severely debilitated patients an aminoglycoside also. Complications: Nonfatal complications occurred in 48 (42 percent) of the patients in this series, that is, in 33 of 88 patients (37 percent) in group I and in 15 of 25 patients (56 percent) in group II (Table II). The most common complication, retained gallbladder or common bile duct stones, occurred in 29 patients, whereas 21 patients had infections related to the wound or operative site. Of the patients presenting with acute symptoms in whom postoperative wound sepsis developed, 3 had no antibiotic coverage in the perioperative period, whereas in 11 antibiotic therapy was begun postoperatively. In only 6 of the 49 patients with antibiotic therapy begun preoperatively and continued postoperatively did infections develop. Conversely, in only one patient in the nonacute patient population did a wound infection develop. Other complications directly related to surgery included hemorrhage along the drain tract [2], pneumonia [3] and persistent biliarj fistula [4].
665
Skillings et al
MLE 30 25
=n
FDHLE
- 9,
TOTAL
=
n
n 15 1* 5
Figure 7. Age and distribution by sex of patients who underwent cholecystosfomy between 7967 and 1977.
3 L
m-25
Figure 2. Proportion of patients in the f wo clinical groups in each decade of life.
TABLE
I
TABLE II
Antibiotic Therapy No. of Patients
I
Antibiotic Therapy
Group
Group II
Preoperative only Pre- and postoperative Postoperative only None
3 49 22 14
1 11 12 3
Total
88
27
Results Mortality: Eighteen patients died after operation or reoperation. Eight of these deaths occurred in patients having cholecystostomy for acute cholecystitis, whereas 10 of the deaths occurred in group II patients (Table III). In group I, three deaths occurred at the time of reexploration for definitive cholecystectomy more than 1 month after cholecystostomy. Elimination of these three deaths from consideration results in a mortality of 6 percent (5 of 88) for cholecystostomy performed for acute inflammatory disease of the biliary tract. All five patients had gram-negative septicemia, documented by blood culture, whereas the three patients who died after a second procedure died from a combination of problems including infection, cardiac and respiratory decompensation and hepatic failure. This frequent combination of mortality after cholecystostomy and septic shock was also seen by Bulow et al [I]. 866
In-Hospital Complications
Comolication
Grow I
Grow II
Total
Wound infection lntraabdominal abscess Retained stone Gallbladder Common bile duct Hemorrhage Pneumonia Fistula Pulmonary embolus
13 7
1 0
14 7
11 14 1 2 3 1
3 1 1 1 1 0
14 15 2 3 4 1
Total
52
8
60
Conversely, in the nonacute group of patients, the mortality was 10 of 27 patients or 37 percent. These deaths were largely the result of incurable malignancies necessitating palliative cholecystostomy or were secondary to severe associated multisystem disease. Follow-up: Follow-up data through at least 1 year were available in 97 of the 115 patients in the study. Of these, 18 have died, 45 have undergone definitive cholecystectomy, and 34 have remained asymptomatic without further operative intervention. Of those having further surgery, 29 had retained calculi in the gallbladder or common duct as one indication for the procedure, whereas the remaining patients were asymptomatic at the time of elective cholecystectomy. The Amerlcan Journal of Surgery
Cholecystostomy
procedures are at times necessary in the treatment of appendiceal abscesses and perforated diverticulitis, so too in comparable biliary tract disease cholecystostomy finds its niche. The procedure can usually be performed rapidly through a small incision with the patient under light general or local anes-
Comments Although cholecystostomy accounts for less than 5 percent of operations on the biliary tract at our hospital, it remains a favored alternative to cholecystectomy in selected circumstances. Just as staged
TABLE Patient NC’.
--
Ill
Mortality _____ Age (yr) & Sex
Cause
Time
Other Diseases Group
57 M
>30 days
E. coli sepsis at reoperation
74 M
Acute
57 M
Acute
E. coli/ Klebsiella E. coli sepsis
78 M
Acute
E. coli sepsis
5
55 F
Sepsis/Klebsiella
6
69 M
>30 days >a0 days
7
80 F
Acute
8
72 M
Acute
1
E. coli sepsis, respiratory failure E. coli sepsis, carcinomatosis Sepsis
Antibiotics Postoperative Preoperative
I
Carcinoma of the lung cirrhosis of the liver with portal hypertension ASCVD
Gentamicin; ampicillin
Ampicillin
High blood pressure, carcinoma of the lung ASCVD perforated gallbladder with peritonitis Carcinoma of the colon, retained stone Diabetes mellitus, ASCVD, high blood pressure, COPD Carcinoma of the colon
Clindamycin
Kanamycin
Ampicillin
Kanamycin and KeflinQ
Penicillin
Penicillin
COPD, ASCVD. peritonitis
Ampicillin
Chloramphenicol
Group II _ 1
82 F
Acute
CVA
2
57 M
3
86 F
>30 days Acute
Carcinoma of the pancreas Myocardial infarction
4
58 M
Acute
5
78 M
6
65 M
>30 days Acute
7
73 F
Acute
8
36 F
Acute
9
67 M
Acute
10
86 M
Acute
Ruptured mycotic abdominal aortic aneurysm Carcinoma of the pancreas Carcinoma of the common bile duct Pulmonary embolus Hemorrhagic pancreatitis Colonic perforation, sepsis Carcinoma of the gallbladder
RXVD = arteriosclerotic E. coli = Escherichia coli.
Volume 139, June 1980
cardiovascular
ASCVD, diabetes mellitus, COPD
Kanamycin
Gentamicin ampicillin ASCVD, COPD, carcinoma of the pancreas with metastasis to liver Salmonella sepsis
COPD, ASCVD Diabetes mellitus
Keflin
Keflin
Keflin
Keflin Ampicillin
Diabetes mellitus Chronic asthma, bronchitis Hemophilia
Chloramphenicol
Chloramphenicol Keflin
ASCVD, diabetes mellitus, COPD
disease; COPD = chronic obstructive
pulmonary disease; CVA = cerebrovascular
accident;
867
Skillingset al
thesia, thus minimizing operative insult to precariously ill or toxic patients. In other situations, it can provide decompression of the biliary tree and prevent the need for extensive dissection through tissue planes obliterated by the inflammatory process, thus protecting the patient from potential biliary complications when the primary operative procedure involves another organ system. In the last 2 decades many surgeons have reaffirmed the value of cholecystostomy. Although labeled an “unwanted stepchild” in the family of surgical procedures, Ross and Dunphy [2] along with Glenn [3], Sparkman [4], Gagic and Frey [5], Havard and Parry [6] and Welch and Malt [ 71 emphasize its importance in selected circumstances. The multiple factors that often enter into the decision to perform cholecystostomy include intraoperative deterioration of the patient’s condition, technical problems and associated preexisting conditions such as cardiovascular, renal, hepatic or pulmonary diseases, diabetes mellitus or gram-negative septicemia. Physiologic age is an important secondary factor in such a decision. The advantages of this procedure are not reflected in reported mortality rates. Compared with the generally accepted mortality rate of less than 6 percent for emergency cholecystectomy, the mortality rate for cholecystostomy has been reported to be 20 to 25 percent by Welch and Malt [ 71, Field and Jones [S] and Gingrich et al [9] and as high as 30 percent by Costello [IO]. In general, this high mortality reflects the condition of the patients who are often poor risks for any operation. The overall mortality in this series (18 of 115 patients) was 15.6 percent, the majority of deaths occurring in the nonacute patient population (10 of 27, or 37 percent), whereas the mortality for cholecystostomy in the presence of acute cholecystitis was 5 of 88 or 5.7 percent. The reason for our relatively low mortality in patients with an acute condition is unclear, although a willingness to perform cholecystostomy as a primary temporizing procedure rather than after extensive dissection in a futile attempt at cholecystectomy may have improved our results. The average age and distribution of our patient population appears similar to those reported by others. Another factor contributing to the low mortality in our series may be the beneficial use of antibiotics liberally pre-, intra- and postoperatively in the acutely ill patients, thus possibly converting a fatal complication to a nonfatal one. Technique may also affect survival statistics. If cholecystostomy is performed for acute cholecystitis and if no clear bile flows through the cystic duct, the surgeon must obtain radiographic evidence of a
066
patent cystic duct. If not, the common bile duct must be diseased. In the past patients with acute ascending cholangitis may have been treated without truly adequate drainage of the biliary system, thus resulting in a higher mortality. Of the five patients with acute cholecystitis who died, all had irreversible gram-negative shock, even with an adequately functioning cholecystostomy. The higher mortality in our nonacute patients generally reflects the nature of the patients’ diseases. Five had carcinoma, three had severe cardiovascular disease, one had hemorrhagic pancreatitis, and one had a massive pulmonary embolus 3 days postoperatively. The importance of postcholecystostomy cholangiography was emphasized by Welch and Malt [7] and is demonstrated again in our series. In 25 patients in group I and 14 in group II, retained stones in the gallbladder or common bile duct were demonstrated by cholangiography. Subsequent cholecystectomy is recommended for patients with retained stones, but the question of whether cholecystectomy is indicated when the initial problem is alleviated by cholecystostomy and there is no retained stone has been posed for years. Hays and Glenn [II] thought that the likelihood of symptomatic biliary tract disease developing more than 2 years after cholecystostomy was greater than 50 percent. Norrby and Schijnebeck [12] reported an 83 percent incidence of recurrent calculi after cholecystostomy in patients followed up for 15 years. Conversely, Ross and Dunphy [2] estimated that 50 percent of patients will remain asymptomatic after cholecystostomy, whereas Field and Jones [8] found that 80 percent of their postcholecystostomy patients remained asymptomatic 1 to 12 years after surgery. In our series 45 patients underwent elective cholecystectomy in the 1st year of follow-up, whereas 34 were asymptomatic without further surgery. The 29 patients with retained stones may eventually have become symptomatic, but the course of the 16 without stones who underwent planned, interval cholecystectomy for asymptomatic disease can only be surmised. If they were all to develop symptoms, our recurrence rate would be 56.9 percent, similar to that of Hays and Glenn [II], whereas if these patients remained asymptomatic, our incidence of recurrent disease becomes similar to that of Field and Jones [8], 36.7 percent. Attempting to define a group of patients likely to have recurrent symptoms, Condon and Nyhus [13] divided postcholecystostomy patients into two groups: those who become symptomatic and those who do not. Their data revealed that if cholecystitis develops postoperatively, symptoms will most likely
The American Journal of Surgery
Cholecystostomy
occur within the 1st postoperative year. Welch and Malt [ 71 also reported that in more than 75 percent of their patients, recurrent disease developed within the 1st year after cholecystostomy. They noted that recurrent disease develops in fewer than 12 percent of patients with normal postoperative cholangiograms, whereas recurrent symptoms develop in up to 80 percent of those with retained stones or abnclrmal emptying of the common bile duct. On the basis of our series we believe that t.he patient who has abnormal results on cholangiography sl:ouId undergo prompt cholecystectomy, conditions permitting, even though asymptomatic, whereas the asymptomatic, poor risk patient with a normal appearing ductal syst.em demonstrated by cholangiography should not undergo reoperation because the chance of cholecystitis developing, particularly after 1 year, is minimal. In none of the 34 patients without retained stones followed up more than 1 year has acute cholecystitis or symptoms necessitating an operation developed. Summary Cholecystostomy retains a place in the general surgical armamentarium. In this series of 115 patients undergoing cholecystostomy between 1967 and 1977,68 percent had acute cholecystitis, whereas in tb e remaining patients biliary drainage was undertaken as part of another procedure. The in-hospital mortality rate was 6 percent for the group with acute cholecystitis and 37 percent for the other patients. Forty-five patients subsequently had elective cholecystectomy, 29 of these for radiographically docu-
Volume
139, June 1980
mented retained calculi. Thirty-four patients without retained calculi remained asymptomatic for more than 1 year. On the basis of this experience and the literature cited, we recommend that subsequent to cholecystostomy, cholecystectomy be performed if the patient is in good general health and has a long life expectancy. Conversely, in the aged, ill patient without evidence of retained stones, cholecystostomy may be a lifesaving and curative procedure and the only one needed.
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