RESUMO
BACKGROUND: Laparoscopic cholecystectomy (LC) is the accepted standard treatment for acute cholecystitis (AC) in patients eligible for surgery. Percutaneous cholecystostomy (PC) can provide a permanent treatment for high-risk patients for surgery or act as a bridge for later surgical treatment. This study is an evaluation of the use of PC during the current coronavirus 2019 (COVID-19) pandemic at a single hospital. METHODS: Fifty patients with AC were admitted as of the start of the COVID-19 pandemic in Turkey through June 2020. Patients with pancreatitis, cholangitis, and/or incomplete data were excluded from the study. Data of the remaining 36 patients included in the study were recorded and a descriptive statistical analysis was performed. The patients were divided into three groups: PC (n=14), only conservative treatment with antibiotherapy (OC) (n=14), and LC (n=8). The findings were compared with a group of 70 similar patients from the pre-pandemic period. RESULTS: The mean age of the pandemic period patients was 53 years (range: 26-78 years). The female/male ratio was 1.11. PC was preferred in eight (11%) patients in the same period of the previous year, whereas 14 (39%) patients underwent PC in the pandemic period. Four of the 36 pandemic patients were positive for COVID-19, including one member of the PC group. There was one (7.1%) mortality in the pandemic-period PC group due to cardiac arrest. The length of hospital stay between the groups based on the type of treatment was not statistically significant. CONCLUSION: LC is not recommended during the pandemic period; PC can be an effective and safe alternative for the treatment of AC.
Assuntos
COVID-19 , Colecistite Aguda , Colecistostomia , Adulto , Idoso , Colecistectomia Laparoscópica , Colecistite Aguda/epidemiologia , Colecistite Aguda/cirurgia , Colecistostomia/efeitos adversos , Colecistostomia/métodos , Colecistostomia/mortalidade , Colecistostomia/estatística & dados numéricos , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pandemias , Estudos Retrospectivos , SARS-CoV-2 , TurquiaRESUMO
OBJECTIVE: To improve the results of treatment of acute cholecystitis. MATERIAL AND METHODS: A historical cohort study (1965-2016) included 1248 patients with acute obstructive cholecystitis and 154 patients with acute obstructive cholecystitis combined with ductal complications and obstructive jaundice. Cholecystostomy was used in all patients. A systematic review of the evidence base on the use of cholecystostomy in high-risk patients was carried out. RESULTS: Cholecystostomy through laparotomy was performed in 240 patients for the period 1965-1981. Overall mortality was 3.6%. Staged treatment strategy has been applied since 1982. Laparoscopic cholecystostomy followed by cholecystectomy through laparotomy was performed in 225 patients for the period from 1982 to 1992. Overall mortality rate was 3.2%. Laparoscopic cholecystostomy (n=617) followed by staged laparoscopic cholecystectomy has been applied for the period from 1993 to 2007. Overall mortality decreased up to 1.1%. Indications for laparoscopic cholecystostomy and staged treatment have been limited since 2008 (n=166). Overall mortality rate was 0.6%. The maximum postoperative mortality after cholecystostomy in some years reached 14.8%.Simultaneous surgeries through laparotomy in patients with acute obstructive cholecystitis and ductal complications were followed by mortality rate 8%, staged laparoscopic cholecystostomy and other minimally invasive technologies (endoscopic papillosphincterotomy with lithoextraction and laparoscopic cholecystectomy) - 4.7%. CONCLUSION: External drainage of the gallbladder is more effective as additional method within staged minimally invasive treatment of complicated cholecystitis rather separate operation. Further analysis of treatment of high-risk patients with acute cholecystitis (as most often selected for cholecystostomy) is required considering the absence of evidence base on this issue.
Assuntos
Colecistite Aguda/cirurgia , Colecistostomia/efeitos adversos , Colecistostomia/mortalidade , Colecistectomia , Humanos , Laparoscopia , Estudos RetrospectivosRESUMO
BACKGROUND: Data regarding long-term outcomes following percutaneous cholecystostomy (PC) are limited, and comparisons to cholecystectomy (CCY) are lacking. We hypothesized that chronic disease burden would predict 1-year mortality following PC, and that outcomes following PC and CCY would be similar when controlling for preprocedural risk factors. METHODS: We performed a 10-year retrospective cohort analysis of patients with acute cholecystitis managed by PC (n = 114) or CCY (n = 234). Treatment response was assessed by systemic inflammatory response syndrome (SIRS) criteria at PC/CCY and 72 h later. Logistic regression identified predictors of 30-day and 1-year mortality following PC. PC and CCY patients were matched by age, Tokyo Guidelines (TG13) cholecystitis severity grade, and VASQIP calculator predicted mortality (n = 42/group). RESULTS: The presence of SIRS at 72 h following PC was associated with 30-day mortality [OR 8.9 (95% CI 2.6-30)]. SIRS at 72 h was present in and 21.4% of all PC patients, significantly higher than unmatched CCY patients (4.7%, p = 0.048). Independent predictors of 1-year mortality following PC were DNR status [19.7 (2.1-186)], disseminated cancer [7.5 (2.1-26)], and congestive heart failure [3.9 (1.4-11)]. PC patients with none of these risk factors had 17.9% 90-day mortality and no deaths after 90 days; late deaths continued to occur among patients with DNR, CHF, or disseminated cancer. At baseline, PC patients had greater acute and chronic disease burden than CCY patients. After matching, PC and CCY patients had similar age (69 vs. 70 years), TG13 grade (2.4 vs. 2.4), and predicted 30-day mortality (5.5 vs. 6.8%). Matched PC patients had higher 30-day mortality (14.3 vs. 2.4%, p = 0.109) and 180-day mortality (28.6 vs. 7.1%, p = 0.048). CONCLUSIONS: Treatment response to PC predicted 30-day mortality; DNR status, and chronic diseases predicted 1-year mortality. Although the matching procedure did not eliminate selection bias, PC was associated with persistent systemic inflammation and higher long-term mortality than CCY.
Assuntos
Colecistectomia/métodos , Colecistite Aguda/cirurgia , Colecistostomia/métodos , Adulto , Idoso , Colecistectomia/mortalidade , Colecistostomia/mortalidade , Estudos de Coortes , Efeitos Psicossociais da Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Síndrome de Resposta Inflamatória Sistêmica/epidemiologia , Síndrome de Resposta Inflamatória Sistêmica/etiologia , Resultado do TratamentoRESUMO
The optimal timing of percutaneous cholecystostomy for severe acute cholecystitis is unclear. The aim of this study was to investigate the timing of percutaneous cholecystostomy and its relationship to clinical outcomes in patients with inoperable acute severe cholecystitis.From 2008 to 2010, 209 consecutive patients who were admitted to our hospital due to acute cholecystitis and were treated by percutaneous cholecystostomy were retrospectively reviewed. The time periods from symptom onset to when percutaneous cholecystostomy was performed and when patients were discharged were recorded.In the 209 patients, the median time period between symptom onset and percutaneous cholecystostomy was 23âhours (range, 3-95âhours). The early intervention group (≤24âhours, nâ=â109) had a significantly lower procedure-related bleeding rate (0.0% vs 5.0%, Pâ=â0.018) and shorter hospital stay (15.8â±â12.9 vs 21.0â±â17.5 days) as compared with the late intervention group (>24âhours, nâ=â100). Delayed percutaneous cholecystostomy was a significant independent factor for a longer hospital stay (odds ratio 3.03, Pâ=â0.001).In inoperable patients with acute severe cholecystitis, early percutaneous cholecystostomy reduced hospital stay and procedure-related bleeding without increasing the mortality rate.
Assuntos
Colecistite Aguda/cirurgia , Colecistostomia/efeitos adversos , Colecistostomia/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Complicações Pós-Operatórias/epidemiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Colecistostomia/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/mortalidade , Estudos Retrospectivos , Fatores Sexuais , Fatores de TempoRESUMO
BACKGROUND: Percutaneous cholecystostomy (PC) can be used to treat patients with acute calculous cholecystitis (ACC) who are considered to be unfit for surgery. However, this procedure has been insufficiently investigated. This paper presents the results of a 10-year experience with this treatment modality. METHODS: A retrospective observational study of all consecutive patients treated with PC for ACC in the period from 1 May 2002 to 30 April 2012 was conducted. All data were collected from patients' medical records. RESULTS: A total of 278 patients were treated with PC for ACC. Of these, 13 (4.7%) died within 30 days, 28 (10.1%) underwent early laparoscopic cholecystectomy and three (1.1%) patients were lost from follow-up. Of the remaining 234 patients, 55 (23.5%) were readmitted for the recurrence of cholecystitis. In 128 (54.7%) patients, PC was the definitive treatment (median follow-up time: 5 years), whereas 51 (21.8%) patients were treated with elective laparoscopic cholecystectomy. The frequency of recurrence of cholecystitis in patients with contrast passage to the duodenum on cholangiography was lower than that in patients without contrast passage (21.1% versus 36.7%; P = 0.037). CONCLUSIONS: The present study, which is the largest ever conducted in this treatment area, supports the hypothesis that PC is an effective treatment modality for critically ill patients with ACC unfit for surgery and results in a low rate of 30-day mortality.
Assuntos
Colecistite Aguda/cirurgia , Colecistostomia/métodos , Colelitíase/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Colecistectomia Laparoscópica , Colecistite Aguda/diagnóstico , Colecistite Aguda/mortalidade , Colecistostomia/efeitos adversos , Colecistostomia/mortalidade , Colelitíase/diagnóstico , Colelitíase/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente , Seleção de Pacientes , Recidiva , Reoperação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Published guidelines recommend early cholecystectomy for acute cholecystitis in the elderly. Alternatively, percutaneous cholecystostomy can be used in compromised patients. METHODS: We reviewed 806 elderly patients diagnosed with biliary disease retrospectively identified through billing and diagnosis codes. Two hundred sixty-five patients with histologically documented acute cholecystitis were selected. RESULTS: Initially, 75 patients had percutaneous cholecystostomy (Group 1), 64 (24 % underwent interval cholecystectomy, 74 (28 %) early (Group 2), and 127 (48 %) delayed cholecystectomy (Group 3). Group 1 was more likely to have American Society of Anesthesiologists (ASA) scores of 4 when compared to those in Groups 2 and 3 (p = 0.04). No difference existed among the groups when patients with an ASA of 4 were excluded: conversion rates (11 %), biliary leak, bowel injury, need for reoperation, or 30 days mortality. Patients in Group 1 and in Group 3 were five times (p = 0.04) and four times (p = 0.06) more likely, respectively, than those in Group 2 to have recurrent episodes of pancreatitis, cholecystitis, and cholangitis. CONCLUSION: Patients were more likely to have delayed cholecystectomy after initial antibiotic therapy or cholecystostomy without the benefit of a lower conversion rate when compared to the early group, but they had higher recurrent episodes of cholecystitis/pancreatitis or cholangitis.
Assuntos
Colecistite Aguda/cirurgia , Colecistostomia/métodos , APACHE , Idoso , Idoso de 80 Anos ou mais , Fístula Anastomótica/etiologia , Colangite/etiologia , Colecistite Aguda/complicações , Colecistostomia/efeitos adversos , Colecistostomia/mortalidade , Conversão para Cirurgia Aberta , Feminino , Fidelidade a Diretrizes , Humanos , Intestinos/lesões , Laparoscopia , Masculino , Pancreatite/etiologia , Guias de Prática Clínica como Assunto , Recidiva , Estudos Retrospectivos , Fatores de TempoRESUMO
PURPOSE: To evaluate the safety and long-term outcome of percutaneous cholecystostomy (PC) under radiologic guidance for acute calculous cholecystitis (ACC) and acute acalculous cholecystitis (AAC) in all patients undergoing that procedure at our institution. MATERIALS AND METHODS: We performed a retrospective analysis of 111 patients who underwent PC from 2004 to 2012. Patients were divided into two groups: AAC and ACC. For all patients, comorbidity and American Society of Anesthesiologists (ASA) classification were determined. The indications, complications, recurrence rate and long-term outcome for both groups were analysed. The mean follow-up was 55 months. RESULTS: Twenty-four patients with AAC and 87 patients with ACC underwent PC. The most common sonographic findings of ACC and AAC were gallbladder wall thickening (90.9%) and hydrops (72.9%). Twelve of 24 patients with AAC (50%) were hospitalized at the Intensive Care Unit (ICU). Overall, the procedure failed in 2 (1.8%) patients. There were 4 (3.6%) abscesses and 2 (1.8%) fistulas post PC. Drain dislodgment was found without sequelae in 8 (7.2%) patients. Elective cholecystectomy was performed in 35/111 (31.5%). Fifty-one of 87 (58.6%) patients with gallstones underwent cholecystectomy; 36/87 (41.3%) did not undergo surgery due to a too short follow-up or death of nonbiliary disease. In the AAC group, there was no recurrent cholecystitis in 17/24 (70.8%) patients; 3/24 (12.5%) underwent surgery and 4/24 (16.6%) patients died in the ICU. CONCLUSION: PC is a minimally invasive treatment with low complication rate for patients with acute cholecystitis whom considered being at high-risk for urgent cholecystectomy. Good selection (ASA III and IV) and indication is needed in patients with ACC before PC because the majority will be operated later on. AAC can be managed nonoperatively and further treatment might not be needed.
Assuntos
Colecistite Aguda/cirurgia , Colecistostomia/métodos , Abscesso/diagnóstico por imagem , Abscesso/etiologia , Idoso , Colecistite Aguda/diagnóstico por imagem , Colecistostomia/efeitos adversos , Colecistostomia/mortalidade , Edema/diagnóstico por imagem , Edema/etiologia , Feminino , Fístula/diagnóstico por imagem , Fístula/etiologia , Seguimentos , Mortalidade Hospitalar , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Recidiva , Estudos Retrospectivos , Resultado do Tratamento , UltrassonografiaRESUMO
BACKGROUND: The management of people at high risk of perioperative death due to their general condition (high-risk surgical patients) with acute calculous cholecystitis is controversial, with no clear guidelines. In particular, the role of percutaneous cholecystostomy in these patients has not been defined. OBJECTIVES: To compare the benefits (temporary or permanent relief of symptoms) and harms (recurrence of symptoms, procedure-related morbidity) of percutaneous cholecystostomy in the management of high-risk individuals with symptomatic gallstones. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded to December 2012 to identify the randomised clinical trials. We also handsearched the references lists of identified trials. SELECTION CRITERIA: We included only randomised clinical trials (irrespective of language, blinding, or publication status) addressing this issue. DATA COLLECTION AND ANALYSIS: Two review authors collected data independently. For each outcome, we calculated the P values using Fisher's exact test or mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS: We included two trials with 156 participants for this review. The comparisons included in these two trials were percutaneous cholecystostomy followed by early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy (1 trial; 70 participants) and percutaneous cholecystostomy versus conservative treatment (1 trial; 86 participants). Both trials had high risk of bias. Percutaneous cholecystostomy with early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy: There was no significant difference in mortality between the two intervention groups (0/37 versus 1/33; Fisher's exact test: P value = 0.47). There was no significant difference in overall morbidity between the two intervention groups (1/31 versus 2/30; Fisher's exact test: P value = 0.61). This trial did not report on quality of life. There was no significant difference in the proportion of participants requiring conversion to open cholecystectomy between the two intervention groups (2/31 percutaneous cholecystostomy followed by early laparoscopic cholecystectomy versus 4/30 delayed laparoscopic cholecystectomy; Fisher's exact test: P value = 0.43). The mean total hospital stay was significantly lower in the percutaneous cholecystostomy followed by early laparoscopic cholecystectomy group compared with the delayed laparoscopic cholecystectomy group (1 trial; 61 participants; MD -9.90 days; 95% CI -12.31 to -7.49). The mean total costs were significantly lower in the percutaneous cholecystostomy followed by early laparoscopic cholecystectomy group compared with the delayed laparoscopic cholecystectomy group (1 trial; 61 participants; MD -1123.00 USD; 95% CI -1336.60 to -909.40). Percutaneous cholecystostomy versus conservative treatment: Nine of the 44 participants underwent delayed cholecystectomy in the percutaneous cholecystostomy group. Seven of the 42 participants underwent delayed cholecystectomy in the conservative treatment group. There was no significant difference in mortality between the two intervention groups (6/44 versus 7/42; Fisher's exact test: P value = 0.77). There was no significant difference in overall morbidity between the two intervention groups (6/44 versus 3/42; Fisher's exact test: P value = 0.49). The number of participants who underwent laparoscopic cholecystectomy was not reported in this trial. Therefore, we were unable to calculate the proportion of participants who underwent conversion to open cholecystectomy. The other outcomes, total hospital stay, quality of life, and total costs, were not reported in this trial. AUTHORS' CONCLUSIONS: Based on the current available evidence from randomised clinical trials, we are unable to determine the role of percutaneous cholecystostomy in the clinical management of high-risk surgical patients with acute cholecystitis. There is a need for adequately powered randomised clinical trials of low risk of bias on this issue.
Assuntos
Colecistectomia Laparoscópica/métodos , Colecistite Aguda/cirurgia , Colecistolitíase/cirurgia , Colecistostomia/métodos , Antibacterianos/uso terapêutico , Colecistectomia Laparoscópica/efeitos adversos , Colecistectomia Laparoscópica/mortalidade , Colecistite Aguda/etiologia , Colecistolitíase/complicações , Colecistostomia/efeitos adversos , Colecistostomia/mortalidade , Conversão para Cirurgia Aberta/estatística & dados numéricos , Humanos , Tempo de Internação , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de TempoRESUMO
Percutaneous cholecystostomy (PC) is an alternative treatment for acute cholecystitis (AC) in elderly patients with high surgical risk and has lower morbidity and mortality than emergency cholecystectomy. There is controversy about whether cholecystectomy should be performed after PC in elderly high-risk patients. Medical records of patients with AC admitted to the Department of Surgery, Jinling Hospital, Nanjing University School of Medicine, China, between January 2004 and July 2009 were reviewed retrospectively. The elderly high-risk patients with AC who underwent PC were selected for further study. The safety, efficacy, and long-term outcome of PC without cholecystectomy were evaluated in these patients. The symptoms of AC resolved in 98.6 per cent of patients; drainage-related morbidity and mortality rates were 4.1 and 1.4 per cent, respectively. No patient underwent cholecystectomy after PC. The recurrence rate of cholecystitis was 4.1 per cent. The one-year survival rate was 82.2 per cent, and the three-year survival rate was 39.7 per cent. No death was related to cholecystitis, but one patient died of septic shock on the second day after PC. Considering limited survival and a low recurrence rate of cholecystitis in elderly high-risk patients with AC, we propose that PC is a definitive treatment and cholecystectomy is not necessary after resolution of AC symptoms.
Assuntos
Colecistite Aguda/cirurgia , Colecistostomia/métodos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Colecistite Aguda/mortalidade , Colecistostomia/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Complicações Pós-Operatórias/epidemiologia , Recidiva , Estudos Retrospectivos , Risco , Resultado do TratamentoRESUMO
BACKGROUND: Percutaneous cholecystostomy is an alternative treatment for acute cholecystitis patients with high surgical risk. METHODS: One hundred and sixty-six patients consecutively treated by percutaneous cholecystostomy for acute cholecystitis in a single medical center were retrospectively reviewed. RESULTS: The cohort included 121 males and 45 females with mean age of 75.9 years. The overall inhospital mortality rate was 15.1 % (n = 25). Elevated serum creatinine level at diagnosis [odds ratio (OR) 1.497; p = 0.020], septic shock (OR 11.755; p = 0.001), and development of cholecystitis during admission (OR 7.256; p = 0.007) were predictive of inhospital mortality. Of 126 patients who recovered from calculous cholecystitis, 11 experienced recurrent cholecystitis within 2 months. Serum C-reactive protein (CRP) level >15 mg dl(-1) at diagnosis [hazard ratio (HR) 10.141; p = 0.027] and drainage duration of cholecystostomy longer than 2 weeks (HR 3.638; p = 0.039) were independent risk factors of early recurrence. The 53 patients who underwent cholecystectomy had an 18.9 % perioperative complication rate and no operation-related mortality. CONCLUSIONS: In-patients or those with septic shock or renal insufficiency have worse outcome. Prolonged drainage duration and high CRP level predict early recurrence. Removal of the drainage tube is recommended after resolution of the acute illness.
Assuntos
Colecistite Aguda/cirurgia , Colecistostomia/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Proteína C-Reativa/metabolismo , Colecistectomia/estatística & dados numéricos , Colecistite Aguda/sangue , Colecistite Aguda/complicações , Colecistite Aguda/mortalidade , Colecistostomia/mortalidade , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/epidemiologia , Modelos de Riscos Proporcionais , Recidiva , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Percutaneous cholecystostomy (PC) is an alternative treatment in acute cholecystitis (AC) in high-risk or elderly patients although its advantage over emergency cholecystectomy has not yet been established. STUDY DESIGN: AC prospective database analysis in high-risk patients treated by PC (group 1, 29 patients) or emergency cholecystectomy (group 2, 32 patients). Surgical risk was estimated by physiological POSSUM, Charlson, Apache II, and American Society of Anesthesiologists (ASA) scores. RESULTS: The groups showed homogeneity concerning age and surgical risk. PC allowed AC resolution in 19 patients (70.4%), but 8 (29.6%) needed emergency cholecystectomy. Morbidity and mortality rates were 31% and 17.2%, respectively. Mortality was significantly associated with ASA IV (P = .01). In group 2, the morbidity rate was 28.1% without mortality. There was no statistical difference in morbidity (P = .6) although mortality was significantly higher in group 1 (P = .02). CONCLUSIONS: PC seems of little benefit and ought to be left for those very old patients with surgical contraindication.
Assuntos
Colecistectomia , Colecistite Aguda/cirurgia , Colecistostomia , Tratamento de Emergência/métodos , Seleção de Pacientes , Idoso , Idoso de 80 Anos ou mais , Colecistectomia/efeitos adversos , Colecistectomia/mortalidade , Colecistectomia Laparoscópica/efeitos adversos , Colecistostomia/efeitos adversos , Colecistostomia/métodos , Colecistostomia/mortalidade , Fatores de Confusão Epidemiológicos , Bases de Dados Factuais , Emergências , Feminino , Humanos , Masculino , Estudos Prospectivos , Projetos de Pesquisa , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Falha de Tratamento , Resultado do TratamentoRESUMO
BACKGROUND: The aim if this study was to compare percutaneous drainage (PD) of the gallbladder to emergency cholecystectomy (EC) in a well-defined patient group with sepsis related to acute calculous/acalculous cholecystitis (ACC/AAC). METHODS: Between 2001 and 2007, all consecutive patients of our ICU treated by either PD or EC were retrospectively analyzed. Cases were collected from a prospective database. Percutaneous drainage was performed by a transhepatic route and EC by open or laparoscopic approach. Patients' general condition and organ dysfunction were assessed by two validated scoring systems (SAPS II and SOFA, respectively). Morbidity, mortality, and long-term outcome were systematically reviewed and analyzed in both groups. RESULTS: Forty-two patients [median age = 65.5 years (range = 32-94)] were included; 45% underwent EC (ten laparoscopic, nine open) and 55% PD (n = 23). Both patient groups had similar preoperative characteristics. Percutaneous drainage and EC were successful in 91 and 100% of patients, respectively. Organ dysfunctions were similarly improved by the third postoperative/postdrainage days. Despite undergoing PD, two patients required EC due to gangrenous cholecystitis. The conversion rate after laparoscopy was 20%. Overall morbidity was 8.7% after PD and 47% after EC (P = 0.011). Major morbidity was 0% after PD and 21% after EC (P = 0.034). The mortality rate was not different (13% after PD and 16% after EC, P = 1.0) and the deaths were all related to the patients' preexisting disease. Hospital and ICU stays were not different. Recurrent symptoms (17%) occurred only after ACC in the PD group. CONCLUSIONS: In high-risk patients, PD and EC are both efficient in the resolution of acute cholecystitis sepsis. However, EC is associated with a higher procedure-related morbidity and the laparoscopic approach is not always possible. Percutaneous drainage represents a valuable intervention, but secondary cholecystectomy is mandatory in cases of acute calculous cholecystitis.
Assuntos
Colecistectomia/métodos , Colecistite Aguda/cirurgia , Colecistostomia/métodos , Tratamento de Emergência/métodos , Mortalidade Hospitalar/tendências , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Causas de Morte , Colecistectomia/mortalidade , Colecistite Aguda/diagnóstico , Colecistostomia/mortalidade , Estudos de Coortes , Estado Terminal/mortalidade , Estado Terminal/terapia , Bases de Dados Factuais , Drenagem/métodos , Tratamento de Emergência/mortalidade , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Sepse/mortalidade , Sepse/cirurgia , Estatísticas não Paramétricas , Análise de Sobrevida , Resultado do TratamentoRESUMO
Antecedentes: La colecistostomía percutánea (CP) en pacientes de alto riesgo quirúrgico. Objetivo: Comunicar la experiencia con este procedimiento en los últimos 10 años. Lugar de aplicación: Centro de referencia de nivel terciario. Diseño: Estudio observacional retrospectivo de base prospectiva. Población: 95% CP consecutivas en el período 1997-2007. Método: Los pacientes con CA y riesgo quirúrgico aumentado fueron estratificados en 4 grupos: estado crítico, comorbilidades crónicas, colecistitis por-intervenciones biliares (endoscópica o percutánea) y embarazo en primer o tercer trimestre. Resultados: Se trataron 95 pacientes, 75% varones, con edad promedio de 62,6 +- 15,2 años (r 26-95). Hubo 44 (46,3%) pacientes en estado crítico, 36 (37,9%) con comorbilidades crónicas, 13 (13,6%) pos-intervenciones biliares y 2 (2,1%) embarazos. El 40% fueron colecistitis alitiásicas. Se utilizó la técnica de Seldinger en el 59% y de punción trocar en el 41%; 74% fueron accesos transhepáticos. La CP fue exitosa en 91 pacientes (95,8%) y fracasó en 4: 2 por falla técnica (3,1%) y 2 por falta de respuesta clínica (3,1%); todos ellos fueron operados. S presentaron 10 (10,5%) complicaciones mayores. La mortalidad intrahospitalaria fue del 23%, sin muertes atribuibles al procedimiento o sepsis biliar. Conclusión: La CP es un procedimiento seguro y efectivo en los pacientes con alto riesgo y CA.
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Colecistite/cirurgia , Colecistostomia/efeitos adversos , Colecistostomia/métodos , Colecistostomia/mortalidade , Estudos RetrospectivosRESUMO
Indications for cholecystectomy are limited to clearly symptomatic gallstones. Relatively high failure rates of pain relief are probably caused by incorrect selection of patients for the operation. Contraindications for (laparoscopic) cholecystectomy are related to anaesthesiological considerations. Laparoscopic cholecystectomy was accepted by consensus as the gold standard within 5 years of its introduction. Nevertheless, both the classical open and small-incision cholecystectomies are safe alternatives, and superiority of any one of the three techniques over the others has not been proven. Primary outcome measures (mortality, complications, and symptom relief) seem to be equal for the three techniques. Acute cholecystitis is a complication of gallstones. Generally it is recommended that early cholecystectomy be performed, as delayed cholecystectomy is associated with longer total hospital stay and convalescence due to recurrent cholecystitis episodes. Cholecystostomy is an alternative technique for patients unfit for general anaesthesia. Reported complication and conversion rates in cholecystectomy for acute cholecystitis vary, but are higher than for symptomatic cholecystolithiasis. New developments--such as robot-assisted surgery--are expected to have a significant impact in the near future.
Assuntos
Colecistectomia Laparoscópica/métodos , Colecistite Aguda/cirurgia , Colecistostomia/métodos , Colelitíase/cirurgia , Colecistectomia Laparoscópica/efeitos adversos , Colecistectomia Laparoscópica/mortalidade , Colecistite Aguda/complicações , Colecistostomia/efeitos adversos , Colecistostomia/mortalidade , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Robótica/métodosRESUMO
Percutaneous cholecystostomy (PC) has been proposed as a method of biliary decompression in critically ill patients with acute cholecystitis. We evaluated the efficacy of PC in this setting. The charts of 33 critically ill patients (mean age 52, range 5-87) who underwent PC for suspected acute cholecystitis were retrospectively examined. Univariate analysis was performed to identify which patients might benefit from PC. PC was technically successful in all patients with no direct mortality or major complications. Failure to improve within 24 hours was associated with increased mortality (P = 0.02). A total of 22/33 patients improved, 17/33 survived, and 8/33 required surgery. PC delayed definitive operation in two patients. Cholelithiasis was associated with surgical intervention (P = 0.01) but not increased mortality. Favorable prognosticators for survival included gallbladder dilatation (P = 0.01), pericholecystic fluid (P = 0.01), and absence of a pulmonary artery catheter (P = 0.02). Predictors of improvement included gallbladder nonvisualization on hepatobiliary scan (P = 0.047), positive bile cultures (P = 0.017), and initial drainage of < / = 100 cc (P = 0.009). Age, laboratory data, the use of total parenteral nutrition, and intubation did not predict outcome. Nine positive bile cultures prompted antibiotic changes in five cases. Finally, PC was less expensive than open cholecystostomy ($1620 versus $3155). PC is a safe, cost-effective, minimally invasive procedure that has diagnostic and therapeutic value in critically ill patients with acute cholecystitis. The involvement of a general surgeon is important to ensure that those patients who do not improve within 24 hours receive early surgical intervention and provide long-term definitive care for those patients with cholelithiasis.
Assuntos
Colecistite/cirurgia , Colecistostomia , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Criança , Pré-Escolar , Colecistite/diagnóstico por imagem , Colecistostomia/efeitos adversos , Colecistostomia/economia , Colecistostomia/métodos , Colecistostomia/mortalidade , Análise Custo-Benefício , Humanos , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Radiografia , Estudos Retrospectivos , Análise de Sobrevida , Resultado do TratamentoRESUMO
A rabbit model for long-term total parenteral nutrition (TPN), specially provided with cholecystostomy tube, was designed to investigate further aspects of TPN-associated cholestasis (TPN-AC). Modified surgical procedures concerning vascular access, cholecystostomy tube implantation and authors' original modalities for prolonged infusion management in the rabbit were used. Continuous TPN was performed in 30 young rabbits. Five animals died during the experiment (16.6%) and were excluded from final evaluation. Twenty-five rabbits were successfully maintained on continuous TPN for 28 days without restraint, having a cholecystostomy tube implanted 1 week after initiation of TPN. The collection of blood samples and daily parenteral administration of drugs were simply accomplished via a central venous catheter. At the same time the cholecystostomy tube enabled us to perform daily bile sampling. Saline irrigation of the biliary tree could be carried out in conscious animals maintained on TPN. A 4-week duration of TPN in this rabbit model made it possible for the first time to accomplish serial liver biopsies in order to verify the evolution of histologic changes in TPN-related hepatic dysfunction and possible effects of surgical and medical treatment. A preliminary analysis of operative findings and histology was carried out. An enlarged gallbladder containing hyperviscous bile was found in 80% of the animals 1 week after initiation of TPN. At this time it was possible to observe the first histologic changes consistent with TPN-associated hepatic disease, such as moderate to severe hepatocyte degeneration and portal inflammation. Biliary sludge was seen after 3 weeks of TPN in 70% of the rabbits, as well as a subsequent progression of TPN-associated histologic findings. Portal fibrosis and fatty liver degeneration occurred in 50% of the rabbits and bile duct proliferation in all animals. After 4 weeks of TPN (at autopsy) gallstones were found in 20% of TPN animals, as well as further progression of bile duct proliferation and fibrosis. Our first experiences with this model and preliminary results suggest that this concept offers new possibilities for further elucidation of TPN-associated hepatic dysfunction.
Assuntos
Colecistostomia , Modelos Animais de Doenças , Nutrição Parenteral , Animais , Biópsia , Cateterismo/métodos , Colecistostomia/mortalidade , Colestase/cirurgia , Feminino , Vesícula Biliar/lesões , Vesícula Biliar/metabolismo , Fígado/metabolismo , Nutrição Parenteral/instrumentação , Nutrição Parenteral/métodos , Coelhos , Trombose/metabolismoRESUMO
This report compares the efficacy of cholecystoenterostomy and choledochoenterostomy for relief of biliary obstruction due to pancreatic cancer. From 1976 to 1988, 109 biliary enteric bypass procedures were performed on patients with pancreatic carcinoma considered unresectable at exploration. Sixty-four of these patients underwent cholecystoenteric anastomosis (CCEA) and 45 choledochoenteric anastomosis (CDEA). Thirty-day operative mortality was 6.3 per cent for CCEA and 8.8 per cent for CDEA; the mean length of survival after operation was 7.8 months for CCEA and 8.9 months for CDEA. Of the 64 patients who underwent CCEA, all but two experienced short-term (greater than 60 days) relief of jaundice and pruritus. These patients were found to have an obstructed cystic duct and a cholecystectomy and choledochojejunostomy were performed. Five other patients in the CCEA group had recurrence of jaundice for an overall failure rate of 10.9 per cent. Operative morbidity in this group was 14 per cent. One of the patients in the CDEA group had an early recurrence of jaundice and three others experienced late recurrence, for an overall failure rate of 8.8 per cent. Operative morbidity in this group was 16 per cent. We conclude that these procedures have comparable morbidity and mortality. Although a few patients with cholecystoenteric anastomosis will develop recurrent jaundice, the simplicity of the procedure, the shorter operative time, and the equivalent relief of symptoms make it a useful procedure and one we believe preferable in high-risk patients.