Colecistitis enfisematosa: presentación de tres casos / Emphysematous cholecystitis: a report of three cases

Antecedentes: la colecistitis enfisematosa (CE) es una forma de presentación infrecuente de la colecistitis aguda. Material y métodos: presentecedentes patológicos, mientras que los otros eran diabéticos. A todos se les realizó tomografía computarizada (TC). Dos pacientes fueron sometidos a colecistectomía videolaparoscópica (CL) con buena evolución, mientras que en un caso se realizó colecistostomía percutánea (CP). Discusión: la CE se refiere a la presencia de gas en la luz o en la pared de la vesícula biliar. La tasa de morbilidad es del 50%. Los pacientes suelen padecer diabetes, pero puede presentarse en pacientes más jóvenes sin factores de riesgo. La TC es el método de elección para el diagnóstico. El tratamiento definitivo es la CL, aunque la CP es otra opción válida. Conclusión: la CL se considera un enfoque eficaz y seguro para el tratamiento de la CE.

Background: Emphysematous cholecystitis (EC) is a rare presentation of acute cholecystitis. Material and methods: We report three cases of EC in two men and one woman between 55 and 79 years. One of the patients was otherwise healthy while the other two were diabetics. A computed tomography (CT) scan was performed in all the cases. Two patients underwent video-assisted laparoscopic cholecystectomy with favorable outcome and one patient underwent percutaneous cholecystostomy. Discussion: Emphysematous cholecystitis is characterized by the presence of gas in the gallbladder lumen or wall. Mortality rate is 50%. Most patients are diabetics, but EC may present in younger patients without risk factors. Computed tomography scan is the method of choice for the diagnosis. Cholecystectomy is indicated as definite treatment, but percutaneous cholecystostomy may be a valid option. Conclusions: Laparoscopic cholecystectomy and antibiotics are effective and safe to treat.

Current Status of Endoscopic Gallbladder Drainage

The gold standard for treatment of acute cholecystitis is laparoscopic cholecystectomy. However, cholecystectomy is often not suitable for surgically unfit patients who are too frail due to various co-morbidities. As such, several less invasive endoscopic treatment modalities have been developed to control sepsis, either as a definitive treatment or as a temporizing modality until the patient is stable enough to undergo cholecystectomy at a later stage. Recent developments in endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with endoscopic ultrasound EUS-specific stents having lumen-apposing properties have demonstrated potential as a definitive treatment modality. Furthermore, advanced gallbladder procedures can be performed using the stents as a portal. With similar effectiveness as percutaneous transhepatic cholecystostomy and lower rates of adverse events reported in some studies, EUS-GBD has opened exciting possibilities in becoming the next best alternative in treating acute cholecystitis in surgically unfit patients. The aim of this review article is to provide a summary of the various methods of gallbladder drainage GBD with particular focus on EUS-GBD and the many new prospects it allows.

Usefulness of Bile Cultures and Predictive Factors for Bacteriobilia in Percutaneous Cholecystostomy in Patients with Acute Cholecystitis / 대한진단검사의학회지

BACKGROUND: Bile cultures have been used to diagnose and predict the prognosis of acute cholecystitis (AC). As the standard treatment for AC has changed, the appropriate timing and clinical usefulness of bile cultures should be reevaluated. We analyzed the incidence of positive bile cultures in cholecystostomy and cholecystectomy, and attempted to see if a positive bile culture is related to the laboratory and imaging parameters and postoperative infections. METHODS: Included in the study were 86 patients with AC who underwent percutaneous cholecystostomy (PC) and then laparoscopic cholecystectomy (LC). We performed hematologic, biochemical, and radiological analyses at admission and bile cultures with each surgical procedure. The patients were followed for two months for postoperative infections. RESULTS: Bile cultures were positive in 40.7% of the patients at PC, significantly higher than at LC (12.8%). The group with positive cultures showed a higher median age and elevated levels of alkaline phosphatase (ALP) and total bilirubin (TB) than the group with negative cultures. Univariate analysis identified three preoperative factors as predictors of positive bile cultures: age (>55 yr), ALP (>100 IU/L) and TB (>1.2 mg/dL). Infectious complications after LC were mild and the incidence of postoperative infections was not different between the groups. CONCLUSIONS: The sensitivity of bile cultures is low for diagnosing AC, and the adequate timing of bile cultures is at PC, rather than LC. An old age and factors (ALP & TB) manifesting an advanced stage of bile stasis are associated with positive bile cultures. No correlation was found between positive bile cultures and postoperative infections.

Usefulness of Bile Cultures and Predictive Factors for Bacteriobilia in Percutaneous Cholecystostomy in Patients with Acute Cholecystitis / 대한진단검사의학회지

BACKGROUND: Bile cultures have been used to diagnose and predict the prognosis of acute cholecystitis (AC). As the standard treatment for AC has changed, the appropriate timing and clinical usefulness of bile cultures should be reevaluated. We analyzed the incidence of positive bile cultures in cholecystostomy and cholecystectomy, and attempted to see if a positive bile culture is related to the laboratory and imaging parameters and postoperative infections. METHODS: Included in the study were 86 patients with AC who underwent percutaneous cholecystostomy (PC) and then laparoscopic cholecystectomy (LC). We performed hematologic, biochemical, and radiological analyses at admission and bile cultures with each surgical procedure. The patients were followed for two months for postoperative infections. RESULTS: Bile cultures were positive in 40.7% of the patients at PC, significantly higher than at LC (12.8%). The group with positive cultures showed a higher median age and elevated levels of alkaline phosphatase (ALP) and total bilirubin (TB) than the group with negative cultures. Univariate analysis identified three preoperative factors as predictors of positive bile cultures: age (>55 yr), ALP (>100 IU/L) and TB (>1.2 mg/dL). Infectious complications after LC were mild and the incidence of postoperative infections was not different between the groups. CONCLUSIONS: The sensitivity of bile cultures is low for diagnosing AC, and the adequate timing of bile cultures is at PC, rather than LC. An old age and factors (ALP & TB) manifesting an advanced stage of bile stasis are associated with positive bile cultures. No correlation was found between positive bile cultures and postoperative infections.

Percutaneous cholecystostomy for acute cholecystitis in 53 high-risk patients / 第三军医大学学报

Objective To evaluate the clinical efficacy and outcomes of percutaneous cholecystostomy(PC) under type-B ultrasonic guide as an alternative treatment option for critically ill patients of acute cholecystitis.Methods The clinical data of 53 high-risk patients of acute cholecystitis were retrospectively analyzed,who received PC from January 1999 to August 2005.Results All cases were successfully punctured and intubated,and 4 received reoperation because of blocked tube or fall-off.Fifty-two(97.3%) gained bile drainage effectively.No complications occurred due to the procedures in the cholecystostomy and intubation.One patient required emergency cholecystectomy on day 1 after the procedures because of deteriorating conditions.Forty-one accepted selective cholecystectomy in 2 weeks to 3 months after cholecystostomy.The follow-up period was 6 months to 3 years.Conclusion PC is an effective,convenient and safe method in managing acute cholecystitis in high-risk patients,with high achievement ratio and less complications.

Percutaneous Cholecystostomy Using Central Venous Catheterization Set with Blue FlexTip Catheter / 한국간담췌외과학회지

PURPOSE: Percutaneous cholecystostomy (PC) using a pig-tail catheter is indicated for high risk acute cholecystitis. However, this procedure is time consuming, expensive and requires radiological equipment. This study compared PC using a pig-tail catheter with central venous catheterization set. METHODS: From January 1992 to June 2003, 44 patients underwent PC without a malignancy or a combined hepato- biliary-pancreatic disease were selected. A retrospective study was performed on the time interval to procedure, cost, complications and therapeutic results of the central venous catheter group (A, 15) and the pig-tail catheter group (B, 29) RESULTS: The time interval was 1.8 days in group A, 3.52 in group B (p=0.002). The cost was 188,684 won in group A, 327,814 won in group B. There were 4 complications in group A (2 leakage, 1 dislodgment, 1 malfunction) while 5 in group B (2 dislodgement, 1 sepsis, 2 malfunction). Although PC, 2 in group A and 5 in group B were discharged hopelessly or died due to the progression of the underlying disease. Twenty-two patients underwent a delayed cholecystectomy with 7 patients in group A (3 laparoscopy, 4 open) and 15 in group B (6 laparoscopy, 8 open, 1 conversion to open). The complication rate was slightly high in group A but there were no statistical significance, no clinical problems and no difference in the mortality rate and surgical method. CONCLUSION: In high risk acute cholecystitis, PC using central venous catheter is easy, economic, effective and performed at early stage in the emergency room by medical doctors or surgeons.

Percutaneous Cholecystostomy and Percutaneous Abscess Drainage in Two Patients of Gallbladder Perforation with High Surgical Risk / 대한소화기내시경학회지

Gallbladder perforation is a grave complication of acute cholecystitis, which has a high incidence of morbidity and mortality in the elderly patients. The unfavorable nature of this disease is due in part to a delay in diagnosis because of the similarity in clinical presentation of patients with uncomplicated cholecystitis and those with perforation. Although prompt surgical intervention with cholecystectomy is the treatment of choice, morbidity and mortality rates rise markedly in the elderly patient with severe systemic illness. In acute cholecystitis, percutaneous cholecystostomy is a good alternative to surgical cholecystectomy or is a temporary measure until a patient is sufficiently stable for surgery. In this report, we describe our experience of successful use of percutaneous cholecystostomy and intra- abdominal percutaneous catheter drainage for the therapy of gallbladder perforation in two patients with high surgical risk.

Fluoroscopically-guided percutaneous cholecystostomy for the treatment of severe acute cholecystitis:an analysis of 31 cases / 介入放射学杂志

Objective To assess the clinical efficacy of fluoroscopically-guided percutaneous cholecystostomy in the treatment of severe acute cholecystitis and to summarize the experience in clinical practice. Methods During the period of Jan. 2006 -Dec. 2008,fluoroscopically-guided percutaneous cholecystostomy was performed in 31 patients with severe acute cholecystitis. The therapeutic results were evaluated by comparing the pre-operative and post-operative laboratory findings and clinical manifestations. Results The procedure of puncture and drainage-tube placement was successfully accomplished in all 31 cases without any complications. One patient with acute renal failure died after the procedure,the remaining 30 patients showed obvious alleviation of symptoms and were discharged with retention of the indwelling drainage-tube. Selective cholecystectomy was carried out in 16 patients with lithic cholecystitis in 1-3 months after percutaneous cholecystostomy. Living with retention of indwelling drainage-tube was chosen by eight patients with lithic cholecystitis. The drainage-tube was extracted in 6 patients with non-lithic cholecystitis in 3-6 weeks after the cholecystitis was cured. Conclusion Fluoroscopically-guided percutaneous cholecystostomy is technically-simple,minimally-invasive and highly-safe treatment for severe acute cholecystitis,it may be regarded as an effective transitive,or even permanent therapy.

Clinical application of percutaneous cholecystostomy in the treatment of high-risk patients with acute cholecystitis / 介入放射学杂志

Objective To discuss the therapeutic strategy and the clinical efficacy of percutaneous cholecystostomy in treating high-risk patients with acute cholecystitis. Methods During the period of Jan. 2006-June 2008,percutaneous cholecystostomy was performed in 27 high-risk patients with acute cholecystitis,consisting of lithic cholecystitis (n = 21) and non-lithic cholecystitis (n = 6). Of 27 patients,percutaneous cholecystostomy via transhepatic approach was performed in 22 and via transperitoneal approach in 5. The 7 F drainage catheter was used. Cholecystography was conducted before the drainage catheter was extracted. Results Percutaneous cholecystostomy was successfully accomplished in all 27 cases,with a technical success rate of 100%. Postoperative patency of gallbladder drainage was obtained in 25 patients,with the relieving or subsiding of abdominal pain and the restoring of temperature and leukocyte account to normal range within 72 hours. In one patient,as the abdominal pain relief was not obvious 72 hours after the procedure,cholecystography was employed and it revealed the obstruction of the drainage catheter. After reopening of the drainage catheter,the abdominal pain was relieved. In another case,cholecystography was carried out because the abdominal pain became worse after the procedure,and minor bile leak was demonstrated. After powerful anti-infective and symptomatic medication,the abdominal pain was alleviated. The drainage catheter was extracted in 25 patients 6-7 weeks after the treatment. Of these 25 patients,12 accepted selective cholecystectomy,7 received percutaneous cholecystolithotomy and 6 with non-lithic cholecystitis did not get any additional surgery. The remaining two patients were living with long-term retention of the indwelling drainage-catheter. Conclusion Percutaneous cholecystostomy is a simple,safe and effective treatment for acute cholecystitis in high-risk patients. This technique is of great value in clinical practice.

Effect of Percutaneous Cholecystostomy on Laparoscopic Cholecystectomy

PURPOSES: A laparoscopic cholecystectomy has many clinical advantages and is now recognize as the choice of treatment for gallstones. However a laparoscopic cholecystectomy is often not feasible or is converted to the conventional open method in patients with acute cholecystitis because of inflammation around the gallbladder, surrounding adhesion, unclear anatomy, or intraoperative complications, such as excessive bleeding, bile duct and other organ injury, or other technical problems. Recent studies recommended that acute cholecystitis patients or gallbladder empyema patients with pain undergo a cholecystostomy first and a laparoscopic cholecystectomy later because a cholecystostomy can be very helpful for improving the patient's state: for example, gallbladder decompression, early control of acute inflammation, and alleviating gallbladder adhesion alleviation. METHODS: This study was carried out on 62 patients (Group I) who underwent a laparoscopic cholecystectomy after a percutaneous cholecystostomy at EulJi Medical College between January 1996 and March 2000. These cases were compared with a control group of 41 patients (Group II) who showed similar symptoms, ultrasonographic findings, operative findings, and pathologic results before January 1996 when a cholecystostomy was not yet used at this hospital. RESULTS: Among Group I, a successful laparoscopic cholecystectomy was possible in 40 patients (64.5%), the other 22 patients were converted to open cholecystectomy. In Group II, only 15 patients (36.6%) out of 41 underwent a successful laparoscopic cholecystectomy. This difference was statistically significant (p=0.005). In other words, the open conversion rates were 35.5% in Group I and 63.4% in Group II. There were no differences in the age and the sexdistributions, the symptom duration, Alk-phosphatase, total bilirubin, and leucocytosis. The degree of inflammation didn't have a singificant influence. Neither did the gallbladder wall thickness. CONCLUSION: We think that a laparoscopic cholecystectomy perfomed some time after a percutaneous cholecystostomy to improve the patient's condition by eliminating acute inflammation or decompressing the gallbladder may be recommended for management of acute cholecystitis patients with severe clinical symptoms and ultrasonographic findings of marked gallbladder dilatation or pericholecystic fluid collection.

Percutaneous Cholecystostomy / 한국간담췌외과학회지

BACKGROUND/AIMS: Cholecystectomy remains the best treatment for acute cholecystitis but may cause high morbidity or mortality in critically ill or elderly patients. METHODS: We performed ultrasonography-guided percutaneous cholecystostomy under local anesthesia in 18 elderly or critically ill patients with suspected acute cholecystitis between 1996 and 1999. RESULTS: Among the 18 patients, 16 had cholecystitis(11 calculous and 5 acalculous); in 2 patients, the procedure was only diagnostic. In 13 of 16 patients with acute cholecystitis, immediate relief of symptoms and significant improvement of laboratory signs of cholecystitis occurred. Persistent signs of cholangitis due to combined common bile duct and intrahepatic duct stones lead to laparotomy in 2 patients. One of these patients died due to pneumonia. Among 13 patients with cholecystitis, 5 patients underwent elective cholecystectomy(4: calculous, 1: acalculous) in 5 and 7 postprocedure days. One laparoscopic cholecystectomy was performed in these patients in 3 months. There was no any operative complication in elective cholecystectomy for these patients. The other 8 patients are symptom-free with an intact gallbladder after mean follow-up period of 17 months. In 2 patients, postprocedure radiologic signs of right pleural effusion were noted but resolved in 10 days in both patients. In one patient minor bleeding was noted but improved by observation only. Mortality rate of a patient with cholecystitis, treated by percutaneous cholecystostomy, was 12.5 percent( 2 of 16). CONCLUSION: These results indicate that percutaneous cholecystostomy is an effective temporary measure in elderly or critically ill patients.

Clinical Study of a Laparoscopic Cholecystectomy after a Percutaneous Cholecystostomy

BACKGROUND: A laparoscopic cholecystectomy has many clinical advantages and is now recognize as the choice for treatment for gallstones. However a laparoscopic cholecystectomy is often not feasible or is converted to the conventional open method in patients with acute cholecystitis because of surrounding adhesion, tissue edema, and high postoperative complications. Lately, good clinical results have been reported by many authors for a percutaneous cholecystostomy followed by a laparoscopic cholecystectomy in the management of acute cholecystitis. METHODS: Between January 1996 and March 1997, 56 acute cholecystitis patients were surgically treated in our institution. Thirteen patients underwent percutaneous drainage followed by a laparoscopic cholecystectomy (Group I). Also a laparoscopic cholecystectomy without a prior percutaneous cholecystostomy was attempted in 43 patients (Group II). RESULTS: There were no differences in the age and the sex distributions, the chief complaints on admission, and the severity of inflammation between the two groups. The only significant difference was the wall thickness of the gallbladder on postoperative pathologic examinations, 4.7 mm for Group I and 6.2 mm Group II (p=0.038). For the patients in Group I, percutaneous drainage of the gallbladder continued for 5.4 days on average, and the cholecystectomy was usually performed about 15 days later. A laparoscopic cholecystectomy was possible in 10 patients (76%) in Group I, but had to be converted to the open method in 3 patients. In Group II, only 17 patients (39.5%) out of 43 underwent a successful laparoscopic cholecystectomy. In other words, the open conversion rate was 24% in Group I and 60.5% in Group II. The wall thicknesses of the gallbladder excised laparoscopically were 3.98 mm and those of the conventionally removed gallbladder were 6.96 mm on average. This difference in the wall thickness was statistically significant (p=0.013) and was the only factor related with the open conversion rate. CONCLUSIONS: We think that a laparoscopic cholecystectomy performed several days after percutaneous drainage of the gallbladder to eliminate acute inflammation may be recommended for management of acute cholecystitis patients with severe clinical symptoms and ultrasonographic findings of marked gallbladder dilatation or pericholecystic fluid collection.

Analysis of Arterial Blood Gas in Acute Cholecystitis Treated by a Percutaneous Cholecystostomy

The Cholecystectomy is the treatment of choice in patients with acute cholecystitis, but non-surgical gall stone therapies, such as a percutaneous cholecystostomy (PC) should be attempted in high risk critically ill patient with acute cholecystitis. Forty critically ill patients with complicated medical and surgical problems underwent an emergency PC at kwanju christran Hospital between 1993 and 1996. Diagnosis were made based on clinical and sonographic findings. The PCs were performed for patients with septic shock (9 cases), severe pain due to gall bladder empyema (9 cases), severe medical problems with acute cholecystitis (16 cases), a previous operation history (3 cases), and refusal of surgery (3 cases). The PCs were successfully performed under ultrasound guidance, and symptoms of patients were improved within several days after the PC. There were no immediate technical complications. We measured the arterial blood gas and analyzed of several factors influencing the acid-base change before and after the PC. The values of the pH and the PCO2 changed with an increasing WBC count, the presence of jaundice, a positive blood culture, a decreasing platelet count, and hypotension but returned to normal within several days after the PC. Although we can not attach statistical significance to the findings, we found that the acid-base balance changed with severe acute cholecystitis, as well as with septic shock and that the clinical symptoms and hemodynamics were improved by the PC. In conclusion, a PC as a nonsurgical management may be the procedure of choice for nonsurgical management of high-risk patients with acute cholecystitis, and as a definitive treatment, a laparoscopic or open cholecystectomy should be performed when symptoms are improved and the patients become stable.