Outcomes of percutaneous cholecystostomy and predictors of eventual cholecystectomy.
Yeo CSW, Tay VWY, Low JK et al. J Hepatobiliary Pancreat Sci. 2016 Jan;23(1):65-73.
This is one of the latest publications examining the use of percutaneous cholecystostomy for acute cholecystitis (AC). This was a retrospective review of cases at a tertiary care hospital in Singapore. ICD-10 codes were used to capture cases over a 10-year period (2005 to 2015), with the aim to look at predictive factors for mortality and eventual cholecystectomy. AC was graded as mild, moderate or severe according to established Tokyo Guidelines (TG13) . A multidisciplinary team approach was used to decide which patients received cholecystosomy. Each patient was then risk stratified after resolution of sepsis with regard to feasibility for eventual cholecystectomy. If cholecystostomy was not offered, then a drain study was obtained between 3 to 6 weeks and the drain was removed if the cystic duct was patent. If the cystic duct was occluded on this cholangiogram, the tube was removed at 3 months if the patient was asymptomatic.
One hundred and three patients were managed with cholecystostomy, of which 28 (27%) were for severe cholecystitis according to TG13. Tubes were placed at a median of 2 days after diagnosis and mostly by direct (not transhepatic) approach. Ten patients had complications of which tube dislodgement was the most common (8 patients). A higher Charlson Comorbidity Index (CCI) was predictive of increased mortality but APACHE II scores were not. In the 29 patients who had attempted laparoscopic cholecystectomy, 5(17%) were converted to open. Eight had open cholecystectomy initially and there was only 1 common bile duct injury in all patients who went on to operation. Patients with higher CCI and age (80.1 ± 12.2 vs. 74.0 ± 12.0) did not receive cholecystectomy. Late cholecystostomy tube placement was significantly associated with mortality.
The study does not compare cholecystostomy to cholecystectomy as an initial procedure. The fate of patients who did not have cholecystectomy is not formally discussed outside of the methods section. This would have been interesting to see since the authors seemed to have a protocol in place with good follow-up, which was lacking in other studies [2,3]. The study methodology may self-select patients with lower CCI to have cholecystectomy since there was a preoperative risk stratification process involved. Therefore, the only finding of importance seems to be that when treating patients with cholecystotosmy, late intervention had higher mortality. The EAST multicenter trial may shed further light on this topic.
- TG13 current terminology, etiology, and epidemiology of acute cholangitis and cholecystitis. Kimura Y, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Garden OJ et al. J Hepatobiliary Pancreat Sci. 2013 Jan;20(1):8-23.
- Use of cholecystostomy tubes in the management of patients with primary diagnosis of acute cholecystitis. Cherng N, Witkowski ET, Sneider EB, et al. J Am Coll Surg. 2012 Feb;214(2):196-201.
- Long-Term Outcomes of Patients with Acute Cholecystitis after Successful Percutaneous Cholecystostomy Treatment and the Risk Factors for Recurrence: A Decade Experience at a Single Center. Wang C-H, Wu C-Y, Yang JC-T, Lien W-C, Wang H-P, Liu K-L, et al. PLoS One. 2016 Jan 28;11(1):e0148017.
Validation and improvement of a proposed scoring system to detect retained common bile duct stones in gallstone pancreatitis. Sherman JL, Shi EW, Ranasinghe NE, Sivasankaran MT, Prigoff JG, Divino CM
Surgery. 2015 Jun;157(6):1073-9.
Key: CBD: Common bile duct; LCIOC: laparoscopic cholecystectomy with intraoperative cholangiogram; MRCP: magnetic resonance cholangiography; ERCP: endoscopic retrograde cholangiopancreatogram; PPV: positive predictive value (calculated as number of patients with CBD stones over the total number of patients for each score); NPV: negative predictive value (calculated as the number of patients without CBD stones over the total number of patients for each score).
This is a prospective study to evaluate a 5 variable decision model for the diagnosis and management of patients with gallstone pancreatitis, who may have CBD stones. The recurrence rate of gallstone pancreatitis and number of biliary complications after gallstone pancreatitis is high (15-30%) and so same admission cholecystectomy is definitive therapy. The group previously identified 5 quantitative variables with cutoffs, using multivariate analysis of retrospective data, that have PPV for CBD stones: CBD size > 9 mm, gamma glutamyl transferase (GGT) >350 U/L, alkaline phosphatase (AP) > 250 U/L, total bilirubin (TB) > 3 mg/ dL, and direct bilirubin (DB) > 2 mg/dL . Values were measured on admission and a point was given for each criteria met. Scores greater than 4 had 92% risk of a CBD stone.
The current study prospectively evaluated a management protocol that incorporated these results: patients with a score of 0 or 1 underwent LCIOC. A patient with a score of 2 was evaluated with MRCP or underwent LCIOC based on attending preference. MRCP was performed for scores of 3 and 4. Patients with a score of 5 had ERCP first. All patients were scheduled for same admission cholecystectomy. Eighty-four patients at Mount Sinai medical Center met inclusion criteria and consented to participate in the study from October 2009 to November 2013. 16 patients had CBD stones based on LCIOC, MRCP or ERCP results. The group with CBD stones was compared to the group without CBD stones. A score of 0 had a 100% NPV. Scores of 4 and 5 had PPV of 67% and 100% respectively. Scores of 1 and 2 had high NPV (81% and 83%, not significant). Scores of 3 had NPV 60%which was not significant. Based on their results the authors propose that patients with a score of 0 have laparoscopic cholecystectomy without cholangiogram, patients with scores of 1-2 have LCIOC and patients with a score of 5 should have ERCP. For a score of 3 that had PPV of 40%, LCIOC or initial MRCP can be employed. For a score of 4 they recommend MRCP initially.
MRCP is recommended in these cases because of high accuracy (>90% in some studies) and a known morbidity of ERCP. Of note, the authors were able to eliminate their 60% negative ERCP rate from their retrospective study in 2009. This is a useful algorithm for management of CBD stones in the face of gallstone pancreatitis that does not rely on serial lab evaluations. The author’s figures 1 and 2 do not match the text so pay attention when referring to these (the authors have been informed of this and are requesting revisions). They propose a multicenter study as the next step in evaluating their protocol.
- Selective management of patients with acute biliary pancreatitis. Telem DA, Bowman K, Hwang J, Chin EH, Nguyen SQ, Di- vino CM. J Gastrointest Surg. 2009 Dec;13(12):2183-8.
Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicentre randomised controlled trial. da Costa DW, Bouwense SA et al. Lancet. 2015 Sep 26;386(10000):1261-1268.
The paper reports the results of the PONCHO (Pancreatitis of biliary origin: Optimal timing of CHOlecystectomy) study, a controlled, multi center, randomized trial  encompassing 23 sites in the Netherlands. It is the first randomized controlled trial to evaluate same admission versus interval cholecystectomy for patients with mild acute gallstone pancreatitis.
Even though there are recommendations for same admission cholecystectomy in gall stone pancreatitis, several centers wait 6 weeks due to concerns of procedural difficulty from pancreatitis related inflammation and edema. The study evaluated all patients admitted with a first episode of gallstone pancreatitis from December 2010 to August 2013. They excluded severe pancreatitis based on persistent organ failure >48hours and CT findings, when available, of necrosis or fluid collections. Patients were enrolled on admission and assigned to one of the study arms 48 hours prior to anticipated discharge. Computer generated randomization was handled centrally.
Primary endpoint was a composite of gallstone related complications (acute readmission for recurrent pancreatitis, cholecystitis, cholangitis, obstructive choledocholithiasis needing ERCP, or gallstone colic) or mortality within 6 months of randomization. Secondary endpoints included difficulty of cholecystectomy, conversion to open cholecystectomy, and hospital length of stay.
Two hundred and sixty six patients out of 713 patients with gallstone pancreatitis were enrolled; 128 were in the same admission cholecystectomy group and 137 were in the interval group. There was no difference in the number of patients in each group who had pre randomization ERCP. Seventeen percent of patients in the interval group had the primary endpoint compared to 5% in the same admission group. In the same admission group the events occurred after cholecystectomy and within 3 weeks of discharge. There was no difference in difficulty, conversion to open, cystic duct leak or bleeding.
The study shows that same admission cholecystectomy for gallstone pancreatitis results in decreased readmission for gallstone related complications and seems to have few complications (although they were not powered to show a difference in procedure related complications). The number of common bile duct injuries is not mentioned. It is interesting to see that in the subgroup of patients who had pre randomization sphincterotomy, there was still a greater number of patients with the primary endpoint in the interval group (although the primary cumulative endpoint includes events related to cholecystitis).
1. Pancreatitis of biliary origin, optimal timing of cholecystectomy (PONCHO trial): study protocol for a randomized controlled trial. Bouwense SA, Besselink MG, van Brunschot S, et al. Trials. 2012 Nov 26;13:225.
Subtotal Cholecystectomy-"Fenestrating" vs "Reconstituting" Subtypes and the Prevention of Bile Duct Injury: Definition of the Optimal Procedure in Difficult Operative Conditions. Strasberg SM, Pucci MJ, Brunt LM, Deziel DJ. J Am Coll Surg. 2016 Jan;222(1):89-96.
The purpose of this review article was to define subtotal cholecystectomy and clarify its variations. Additionally, the author sought to encourage and guide other practitioners in the use of this critical bailout technique.
Laparoscopic cholecystectomy already owns a higher rate of biliary injury and does open cholecystectomy. In cases of acute or chronic inflammation, this procedure is made more difficult. The critical view of safety technique or CVS is an effective way to maintain safety during cholecystectomy. It is not always possible to identify important structures using the CVS technique. In these cases, a bailout technique is necessary to avoid iatrogenic biliary injury and subsequent morbidity for the patient, while concomitantly treating the patient’s condition.
For many years, the techniques of partial or subtotal cholecystectomy have been reported. However, no clear definition of this operation has been established. This article reviewed the subject of partial and subtotal cholecystectomy. It proposed that the technique be described as a subtotal cholecystectomy of either the fenestrated or reconstituting subtype, each of which has advantages and disadvantages. The reconstituting subtype denotes the procedure in which the cut end of the gallbladder is sutured closed. The fenestrated technique, on the other hand, does not occlude the gallbladder, leaving a remnant open. In this procedure suturing of the cystic duct may be performed.
As expected subtotal fenestrated cholecystectomy has the advantage of eliminating the risk of recurrent symptoms which may occur with the remnant gallbladder in the reconstituting type of procedure. However, the obvious disadvantage is the creation of a biliary fistula. It should be noted that most of these fistulas resolve spontaneously unless associated with a distal obstruction, such as a stone in the common bile duct. There is little evidence to quantify the risk of recurrent symptoms in reconstituted or fenestrated gallbladders after subtotal cholecystectomy. Indeed, the authors point out that symptoms can occur even when the residual gallbladder is very small.
The technique associated with each type of subtotal cholecystectomy is as follows: Fenestrated type–#1 the gallbladder is opened along its long axis, #2 stones are emptied, #3 cholangiography or intraoperative ultrasound may be performed, #4 gives the option of leaving the portion of the gallbladder adherent to the liver in place and ablating it or, removing some of the gallbladder attached to the liver, #5 the cut edge of the gallbladder may be oversewn, #6 the cystic duct may be sutured from the inside using fine sutures, if possible, #7 one or 2 closed suction drains are placed.
For the reconstituting type, the lip of gallbladder left in site is generally larger than that with the fenestrated procedure. The lumen of the gallbladder is reestablished by closing together the cut edges of the gallbladder wall. This may be accomplished by staples or sutures.
Next the authors address the question of whether a subtotal cholecystectomy should be done laparoscopically. The literature cited noted a more frequent occurrence of subtotal cholecystectomy with an open approach. They also cited a higher rate of bile leak when the subtotal cholecystectomy was performed via the laparoscopic approach. In summary, the authors stated that the ideal procedure for cholecystectomy in which the CVS cannot be obtained would have the following characteristics: “#1 it does not leave a remnant gallbladder that will become symptomatic and require later operation. #2 has low morbidity due to bile fistula. If a fistula occur it should resolve spontaneously over a short period. #3 Can be done laparoscopically. #4 Can be done by a general surgeon without additional fellowship training in hepato-pancreato-biliary or minimally invasive surgery.” In conclusion, while the decision for laparoscopic versus open approach was left up to the experience and comfort of the performing surgeon, the authors believed that a minimally invasive, subtotal fenestrated cholecystectomy with drain placement would best fulfill the aforementioned qualities listed above. They cautioned that the key principal of subtotal cholecystectomy should not be lost, that is the concept of leaving a “shield” of safety adjacent to the hepatocystic triangle, to prevent inadvertent injury.