1Tariq Ali,2Karen Chan, 1Karen Chan, 2Zahra Al-Alwani, 1Amr Moussa, 1Amr Moussa
1Norfolk & Norwich University Hospital NHS Trust, 2University of Oxford
Percutaneous cholecystostomy (PC) is a minimally invasive image-guided placement of a drainage catheter in the gallbladder, particularly in patients who are considered high risk for definitive laparoscopic cholecystectomy (gold standard). There is a paucity of evidence comparing outcomes between complicated and uncomplicated cholecystitis in patients undergoing percutaneous cholecystostomies.
Material(s) and Method(s):
This is a double armed randomized prospective studAll patients undergoing PC at a single-centre, tertiary unit, between August 2016 and December 2020 were included in the study. 100 patients underwent primary PC as were considered unfit for surgery at the time of diagnosis. Baseline characteristics were recorded. Technical outcomes, complication rates, re-intervention and mortality rates were investigated.
100 patients (47 male, 53 female) mean age 71 (SD 11) years underwent PC. 47 patients were 80 years old or older. 34 of the cases were uncomplicated and 66 were complicated (emphysematous, perforation, gangrenous, biloma). Technical success rate was 100%. 15% subsequently underwent cholecystectomy. 12 patients had reintervention. 30-day mortality rate was 9%, and the 90-day mortality rate was 11%. After 6 months, 84 patients were alive of a total of 97 patients whose data were available.
The outcome in the form of 30-day, 90-day mortality, being alive after 6 months and reintervention are compared between complicated and uncomplicated cases using Chi squared test or Fisher’s exact test. There was no statistically significant difference in any of the compared outcomes (P = 0.135) between the two groups.
Cox proportional hazards model was used to study the factors affecting survival (30 days follow up). This included age, gender, reintervention rates, complicated cholecystitis, CRP, bilirubin levels, WCC and the presence of Acute Kidney Injury (AKI). Univariate and multivariable models are presented using the hazard ratio with the 95% Confidence interval.The only variable that showed statistically significant association with the risk of mortality was the presence of AKI on admission (as per modified RIFLE criteria). Patients who have AKI stage 2 or 3 had a higher hazard for mortality as compared to patients with no kidney disease. For patients with stage 2, HR=10.85 (95% CI: 1.33, 88.49), p-value = 0.026, and for patients with stage 3, HR=25.46 (95% CI: 2.40, 269.88), p-value =0.007. There was no statistically significant difference in hazard of mortality between complicated and uncomplicated cases, p-value = 0.094, or between patients less than 80 years old and those 80 or more, p-value = 0.117. The presence of gallbladder stones also showed no statistically significant association with the hazard of mortality, p-value=0.112.
Our results demonstrate that PC is a safe and effective procedure in patients presenting with acute cholecystitis regardless of whether complicated or uncomplicated as no statistically significant difference was identified between the two groups. The results also highlight the importance of recognising and treating AKI, an independent risk factor affecting mortality.