Open Cholecystostomy Under Local Anesthesia for Acute Cholecystitis in the Elderly and High-Risk Surgical Patients.

BACKGROUND: The morbidity and mortality rates associated with cholecystectomy for acute cholecystitis are higher in the critically ill elderly population. As an alternative to cholecystectomy, we report the results of treatment of acute cholecystitis in the elderly after open cholecystolithotomy with cholecystostomy tube placement under local anesthesia. METHODS: A case series was performed on 5 patients from August 2007 to April 2010 who presented with acute cholecystitis and underwent an open cholecystolithotomy and tube placement. Thirty-day mortality, intra- and immediate-postoperative complications, clinical improvement after drainage, additional biliary procedures needed, and outcome after cholecystostomy tube removal were recorded. RESULTS: Open cholecystolithotomy and tube placement were performed successfully in all patients and permitted resolution of the acute attack in all after a mean period of 3.75 days. Thirty-day mortality was 0%. Patients did not experience any intraoperative complications. We observed 100% rate of successful short-term outcomes in our patients including resolution pain, and objectively, normalization of leukocytosis, and defervescence. None of the patients required emergency cholecystectomy. All patients had their cholecystostomy tubes removed at a mean postoperative day 27. There were no cases of biliary leakage or tube dislodgement. There were no recurrences of acute cholecystitis within the mean follow-up of 20.75 months. DISCUSSION: Emergency open cholecystolithotomy and cholecystostomy tube placement represent an effective, safe, and definitive alternative treatment strategy for acute gallstone cholecystitis in selected elderly patients with a mortality rate of 0% in the authors' experience.

Finding the Most Favorable Timing for Cholecystectomy after Percutaneous Cholecystostomy Tube Placement: An Analysis of Institutional and National Data.

BACKGROUND: Early cholecystectomy (E-CCY; 8 weeks or less) after percutaneous cholecystostomy tube (PCT) placement has been associated with increased postoperative complications, but this finding has not been validated at a national level and PCT-related complications and interventions (PCT-RCIs) were not evaluated. STUDY DESIGN: Adults with PCT for acute cholecystitis subsequently undergoing CCY were identified within the Nationwide Readmission Database (2010-2015) and our institution (2017-2019). Adjusted relative risks (aRRs) of postoperative complications were estimated using Poisson regression comparing E-CCY with delayed cholecystectomy (D-CCY; more than 8 weeks) within the nationwide cohort. Institutional PCT-RCIs, operative data, and postoperative outcomes were compared between E-CCY and D-CCY using chi-square and Kruskal-Wallis tests. RESULTS: Of 6,145 patients from the Nationwide Readmission Database, 32.9% were D-CCY. Risk-adjusted analysis identified no differences between E-CCY and D-CCY in complications (aRR 0.98; 95% CI, 0.89 to 1.07), mortality (aRR 0.88; 95% CI, 0.43 to 1.81), or 30-day readmissions (aRR 1.04; 95% CI, 0.85 to 1.27). Risk-adjusted analyses assessing the association of time to interval cholecystectomy (IC) with morbidity indicated an increased risk of surgical complications in the first month after PCT placement (aRR 1.17; 95% CI, 1.08 to 1.33). In the institutional cohort (E-CCY, n = 23; D-CCY, n = 45), there were no statistically significant differences found in estimated blood loss, length of stay, and postoperative complications. There were increased PCT-RCIs in the D-CCY group (26.9% E-CCY vs 69% D-CCY; p < 0.01) based on our unadjusted analysis. CONCLUSIONS: Increased operative complications when IC is performed within 1 month of PCT placement and increased PCT-RCIs when IC is performed 8 weeks after PCT placement suggest that the most favorable timing for IC is between 4 and 8 weeks after PCT placement.

Two-Center Prospective Comparison of the Trocar and Seldinger Techniques for Percutaneous Cholecystostomy.

OBJECTIVE. The purpose of this study is to compare the safety and efficacy of the bedside ultrasound (US)-guided trocar technique versus the US- and fluoroscopy-guided Seldinger technique for percutaneous cholecystostomy (PC). SUBJECTS AND METHODS. This prospective noninferiority study compared the bedside US-guided trocar technique for PC (the trocar group; 53 patients [28 men and 25 women]; mean [± SD] age, 74.31 ± 16.19 years) with the US- and fluoroscopy-guided Seldinger technique for PC (the Seldinger group; 52 patients [26 men and 26 women], mean age, 79.92 ± 13.38 years) in consecutive patients undergoing PC at two large tertiary university hospitals. The primary endpoints were technical success and procedure-related complication rates. Secondary endpoints included procedural duration, pain assessment, and clinical success after up to 3 months of follow-up. RESULTS. PC was successfully performed for all 105 patients. The clinical success rate was similar between the two study groups (86.8% in the trocar group vs 76.9% in the Seldinger group; p = 0.09). Mean procedural time was significantly lower in the trocar group than in the Seldinger group (1.77 ± 1.62 vs 4.88 ± 2.68 min; p < 0.0001). Significantly more procedure-related complications were noted in the Seldinger group than in the trocar group (11.5% vs 1.9%; p = 0.02). Among patients in the Seldinger group, bile leak occurred in 7.7%, abscess formation in 1.9%, and gallbladder rupture in 1.9%. No procedure-related death was noted. Minor bleeding occurred in one patient (1.9%) in the trocar group, but the bleeding resolved on its own. The mean pain score during the procedure was significantly lower in the Seldinger group than in the trocar group (3.2 ± 1.77 vs 4.76 ± 2.17; p = 0.01). At 12 hours after the procedure, the mean pain score was significantly lower for patients in the trocar group (0.78 ± 1.0 vs 3.12 ± 1.36; p = 0.0001). CONCLUSION. Use of the bedside US-guided trocar technique for PC was equally effective as the Seldinger technique but was associated with fewer procedure-related complications, required less procedural time, and resulted in decreased postprocedural pain, compared with fluoroscopically guided PC using the Seldinger technique.

Comparison of the effectiveness and safety of lumen-apposing metal stents and anti-migrating tubular self-expandable metal stents for EUS-guided gallbladder drainage in high surgical risk patients with acute cholecystitis.

BACKGROUND AND AIMS: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using an anti-migrating tubular self-expandable metal stent (ATSEMS) is performed in high surgical risk patients with acute cholecystitis. The newly introduced lumen-apposing metal stent (LAMS) is expected to reduce the risk of tubular self-expandable metal stent-related adverse events such as stent migration, but no comparative studies have been carried out between LAMSs and ATSEMSs for EUS-GBD. METHODS: We reviewed the prospectively collected EUS-GBD database at Asan Medical Center and Bucheon Soonchunhyang hospital to analyze consecutive patients with acute cholecystitis who underwent EUS-GBD with LAMSs or ATSEMSs between January 2015 and December 2017. Technical success, clinical success, adverse events, and recurrence of cholecystitis were evaluated. RESULTS: A total of 71 patients (36 with LAMSs, 35 with ATSEMSs) were analyzed. The LAMS group had longer median procedure time (15.5 minutes) than the ATSEMS group (11 minutes; P = .017). The 2 groups did not show significant differences in terms of technical success (LAMS, 94% vs ATSEMS, 100%; P = .49), clinical success (94% vs 100%; P = .49), procedure-related adverse events (0% vs 2.9%; P = .99), and stent-related late adverse events (11.8% vs 5.8%; P = .43). During follow-up, the 2 groups had similar rates of cholecystitis recurrence at 6 months (LAMS, 3.4% vs ATSEMS, 3.1%, P = .99) and 12 months (8.3% vs 3.1%, P = .56). CONCLUSIONS: In high surgical risk patients with acute cholecystitis, LAMSs and ATSEMSs for EUS-GBD showed similar rates of technical success, clinical success, procedure-related adverse events, stent-related late adverse events, and recurrence of cholecystitis.

Percutaneous Cholecystolithotomy Using Cholecystoscopy.

The morbidity and mortality of cholecystectomy can increase to 10% in high surgical risk patients. The technique for percutaneous cholecystolithotomy consists of 3 steps: (1) percutaneous cholecystostomy, (2) tract dilation and cholecystolithotomy, and (3) tract evaluation and catheter removal. Cholecystoscopy is critical in guiding the lithotripsy probe for fragmentation of large stones and is useful for locating small stone fragments not seen in cholangiography. Cholecystoscopy is also useful for assessing ambiguous lesions and in distinguishing between stone vs debris or mass. Technical success rate of percutaneous cholecystolithotomy using cholecystoscopy ranges from 93% to 100%. Procedure related complication rate has been reported as 4%-15%. The most common complication is bile leak during the procedure or after catheter removal. Although recurrence rate of gallstones has been reported up to 40%, the symptom recurrence rate is much lower. Therefore, percutaneous cholecystolithotomy using cholecystoscopy can be an alternative to cholecystectomy in high surgical risk patients with symptomatic gallstones.

Cholecystostomy: Are we using it correctly?

BACKGROUND: Percutaneous Cholecystostomy Tubes (PCT) have become an accepted and common modality of treating acute cholecystitis in patients that are not appropriate surgical candidates. As percutaneous gallbladder drainage has rapidly increased newer research suggests that the technique may be overused, and patients may be burdened with them for extended periods. We examined our experience with PCT placement to identify independent predictors of interval cholecystectomy versus destination PCT. METHODS: All patients with cholecystitis initially treated with PCT from 2014 to 2017 were stratified by whether they underwent subsequent interval cholecystectomy. Demographic data, initial laboratory values, Tokyo Grade, Charlson Comorbidity Index, ASA Class, complications related to PCT, complications related to cholecystectomy, and mortality data were retrospectively collected. Descriptive statistics, univariable, and multivariable Poisson regression were performed. RESULTS: 165 patients received an initial cholecystostomy tube to treat cholecystitis. 61 (37%) patients went on to have an interval cholecystectomy. There were 4 complications reported after cholecystectomy. A total of 46 (27.9%) deaths were reported, only one of which was in the cholecystectomy group. Age, Tokyo Grade, liver function tests, ASA Class, and Charlson Comorbidity Index were significantly different between the interval cholecystectomy and no-cholecystectomy groups. Univariable regression was performed and variables with p < 0.2 were included in the multivariable model. Multivariable Poisson regression showed that increasing Tokyo Grade (IRR 0.454, p = 0.042, 95% CI 0.194-0.969); and increasing Charlson Comorbidity Score (IRR 0.890, p = 0.026, 95% CI 0.803-0.986) were associated with no-cholecystectomy. Higher Albumin (IRR 1.580, p = 0.011, 95% CI 1.111-2.244) was associated with having an interval cholecystectomy. CONCLUSION: Patients in the no-cholecystectomy group were older, had more comorbidities, higher Tokyo Grade, ASA Class, and initial liver function test values than those that had interval cholecystectomy. Since interval cholecystectomy was performed with a low rate of complications, we may be too conservative in performing cholecystectomy after drainage and condemning many patients to destination tubes.

First in-Human Gallbladder Cryoablation in a Patient with Acute Calculous Cholecystitis Initially Treated with a Cholecystostomy Tube.

A 71-year-old poor surgical candidate with acute calculous cholecystitis was initially managed with cholecystostomy tube drainage for 28 days. He subsequently underwent gallbladder cryoablation under moderate sedation with 3 cryoprobes and 2 separate 10-8-10 freeze-thaw cycles targeting the gallbladder neck/body and fundus followed by cholecystostomy tube removal. He was discharged 1 day after ablation. Magnetic resonance and hepatobiliary iminodiacetic acid scan 1 month postablation demonstrated a thick-walled, distended gallbladder and no filling of the cystic duct. Magnetic resonance 3 months postablation demonstrated retraction of the gallbladder wall with luminal collapse. The patient denied any pain after discharge and is asymptomatic 3 months after ablation.

[Percutaneous cholecystostomy as treatment for acute cholecystitis at Landspitali University Hospital 2010 - 2016].

INTRODUCTION: Acute cholecystitis is one of the most common reasons for acute admission in abdominal surgery. The recom-mended therapy is cholecystectomy but occasionally that is not possible and a conservative treatment with intravenous antibiotics is used. Should the patient not respond to conservative treatment a percutaneous catheter can be placed in the gallbladder (cholecystostomy). The aim of the study was to look at the frequency of which cholecystostomies were used and the complication rates at Landspitali, The National University Hospital of Iceland. MATERIALS AND METHODS: A retrospective study where patient charts of those with ICD - diagnosis numbers K80 - 85 at Landspitali University Hospital looked at and patients who received cholecystostomies were identified in the period from 2010 - 2016. Clinical information was registered in Excel. Descriptive statistics were used. RESULTS: A total of 4423 patients were diagnosed with biliary disease during the study period. 1255 (28%) of them had acute cholecystitis with mean age of 58 years (range: 18 - 99). A cholecystostomy was put in 88 patients (14%), mean age 71 years (range: 28 - 92). A transhepatic route was used for 62 (70%) and the drain was in place for an average of 12 days (range: 0 - 87). A secondary cholangiography was performed in 71 cases. Seventeen patients were discharged home with the cholecystostomy in place. Half of the patients underwent a laparoscopic cholecystectomy 101 days from drain insertion (range: 30 - 258). A total of 28 complications were noted in 27 patients (31%) and the most common complication was dislodgement of the catheter (n=20). Five patients (6%) died within thirty days of the intervention, three from septic shock and two from reasons unrelated to the treatment. CONCLUSIONS: Cholecystostomy is not a common choice of treatment for acute cholecystitis at Landspitali, The National University Hospital of Iceland. Few serious complications arise from the treatment and no patients died in relation to the intervention.

Percutaneous cholecystostomy-tube for high-risk patients with acute cholecystitis: current practice and implications for future research.

BACKGROUND: While cholecystectomy (CCY) is the standard of care for gallstone-related acute cholecystitis, percutaneous cholecystostomy-tube (CCYT-tube) is an alternative option in patients with significant comorbid conditions. We sought to identify immediate and longitudinal hospital outcomes of patients who underwent CCYT-tube placement and determine predictors of CCYT-tube placement and eventual CCY on a national level in the US. METHODS: We identified all adults (age ≥ 18 years) with a primary diagnosis of acute calculous cholecystitis from January to November 2013 in the Nationwide Readmissions Database (NRD). The NRD allows longitudinal follow-up of a patient for one calendar year. Outcomes of patients undergoing CCY and CCYT-tube were compared. Separate univariable and multivariable regression analyses were performed to identify predictors of CCYT-tube placement and failure to undergo subsequent CCY. RESULTS: A total of 181,262 patients had an index hospitalization with acute cholecystitis where 178,095 (98.3%) patients underwent only CCY and 3167 (1.7%) patients were managed with CCYT-tubes. Among patients with CCYT-tube, 1196 (37.8%) underwent eventual CCY in 2013, while 1971 (62.2%) did not. One in five patients with CCYT-tube were readmitted within 30 days of hospital discharge. Multivariable analysis demonstrated that increasing age, male gender, coronary artery disease, cirrhosis, atrial fibrillation, diastolic congestive heart failure, and sepsis were associated with CCYT-tube placement. Longitudinal follow-up revealed that older age (OR 1.16, 95% CI 1.09-1.23), Elixhauser comorbidity score 3-4 (OR 1.94, 95% CI 1.03-3.63), cirrhosis (OR 3.28, 95% CI 1.59-6.79), and diastolic congestive heart failure (OR 2.47, 95% CI 1.33-4.60) were associated with failure to undergo subsequent CCY. CONCLUSION: In this national survey, nearly two in three patients who receive CCYT-tube for acute cholecystitis do not get CCY during longitudinal data capture within the same calendar year. Future research needs to target novel options for drainage of the gallbladder in high-risk patient populations.

The impact of a percutaneous cholecystostomy catheter in situ until the time of cholecystectomy on the development of recurrent acute cholecystitis: a historical cohort study.

BACKGROUND: the optimal duration of percutaneous cholecystostomy in patients with acute cholecystitis is unknown. METHODS: this study was a retrospective analysis of patients (age ≥ 18 years) who underwent percutaneous cholecystostomy due to acute calculous cholecystitis. Patients were grouped according to treatment modality: percutaneous cholecystostomy as a definitive treatment (group 1), subsequent surgical treatment after the removal of the catheter (group 2) and those remaining in situ (group 3). The development of gallstone-related complications was the main outcome. RESULTS: there were 24 females (43.6%) and 31 males (56.4%) included in the study with a mean age of 64.8 ± 15.9 years. There were 16 (29.1%), 19 (34.5%) and 20 (36.4%) patients in groups 1, 2, and 3, respectively. The catheter withdrawal time for group 1 and group 2 was 18.2 ± 6.9 and 20.7 ± 13.4 days, respectively. Surgical treatment was performed after a mean of 85.4 ± 93.5 days following catheter removal in group 2 and a mean of 64 ± 32.5 days while the PC tube was in place in group 3. There were one (6.3%) and two cases of a recurrence (10.5%) in groups 1 and 2, respectively. Two patients developed choledocholithiasis (10%) in group 3. CONCLUSION: maintaining percutaneous cholecystostomy tubes in place until the time of surgery in surgically fit patients may help to prevent a recurrence after acute calculous cholecystitis.

Role of Percutaneous Cholecystostomy Tube Placement in the Management of Acute Calculus Cholecystitis in High Risk Patients.

OBJECTIVE: To evaluate the utility of percutaneous cholecystostomy tube in patients with acute calculus cholecystitis, who are considered unfit for immediate surgery. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi, Pakistan, from January 2010 to December 2014. METHODOLOGY: All adult patients who underwent percutaneous cholecystostomy tube placement for acute calculous cholecystitis were included. These patients were divided into two groups for further analysis. Group-I consisted those who had interval cholecystectomy after tube placement and Group-II were those who had no further treatment. Recurrence of symptoms, infections and operation related complications were noted. RESULTS: Sixty-five patients met the inclusion criteria. Mean age was 58.5 years. Forty-four patients (67.7%) were males. Forty-three patients underwent interval cholecystectomy (Group-I) and 22 did not (Group-II). Mean operative time was 134.9 +57.8 minutes. Five (11.6%) patients were converted to open cholecystectomy, two (4.6%) developed CBD injury, and seven (16.2%) developed surgical site infection. In Group-II, three patients (13.6%) developed recurrence of symptoms and 19 (86.4%) remained symptom-free. Catheter related problems occurred in four (18%) patients. Mean follow-up was 19 +8 months. CONCLUSION: Percutaneous cholecystostomy is a good alternative for patients unfit to undergo immediate surgery. Recurrence of symptoms after tube removal are in a low range; therefore, it can be considered a definitive management for high risk patients. Laparoscopic cholecystectomy after tube placement becomes technically challenging.

Endoscopic Ultrasound-Guided Gallbladder Drainage.

Recent literature has demonstrated effectiveness and safety of endoscopic ultrasound-guided gallbladder drainage, both as a primary intervention in patients with cholecystitis who are unfit for urgent surgical intervention and as a secondary intervention to internalize biliary drainage after initial placement of a percutaneous cholecystostomy catheter.

Long-Term Outcomes Following Percutaneous Cholecystostomy Tube Placement for Treatment of Acute Calculous Cholecystitis.

INTRODUCTION: Percutaneous cholecystostomy tube (PCT) placement is considered a safe alternative to cholecystectomy for the treatment of acute calculous cholecystitis (ACC), but data regarding long-term outcomes following PCT are limited. METHODS: We retrospectively reviewed our institutional experience of patients undergoing PCT for ACC between 1997 and 2015. Recurrent biliary events were defined as cholecystitis, cholangitis, or gallstone pancreatitis. RESULTS: PCT was placed for 288 patients with ACC. Mean age and age-adjusted Charlson comorbidity index were 72 ± 15 years and 5.3 ± 2.4, respectively. Following PCT placement, 91% of patients successfully resolved their episode of ACC. PCT dysfunction occurred in 132 patients (46%), with 80 patients (28%) requiring re-intervention, while 7% developed procedure-related complications. Interval cholecystectomy reduced the risk of recurrent biliary events to 7% from 21% (p = 0.002). Cholecystectomy was completed laparoscopically in 45% of patients receiving an interval operation vs. 22% of those undergoing urgent surgery for PCT failure or recurrent biliary event (p = 0.03). CONCLUSIONS: PCT placement is a highly successful treatment for acute calculous cholecystitis and is associated with low complication rate, but high rate of tube dysfunction requiring frequent re-intervention. Interval cholecystectomy is associated with a decreased likelihood of recurrent biliary events and increased likelihood of successful laparoscopic completion.

What is the fate of the cholecystostomy tube following percutaneous cholecystostomy?

INTRODUCTION: Cholecystectomy is the preferred treatment for acute cholecystitis with percutaneous cholecystostomy (PC) considered an alternative therapy in severely debilitated patients. The aim of this study was to evaluate the efficacy and outcomes of PC at a tertiary referral center. METHODS: We retrospectively reviewed all patients that had undergone PC from 2000 to 2014. Data collected included baseline demographics, comorbidities, details of PC placement and management, and post-procedure outcomes. The Charlson comorbidity index (CCI) was calculated for all patients at the time of PC. RESULTS: Four hundred and twenty-four patients underwent PC placement from 2000 to 2014, and a total of 380 patients had long-term data available for review. Within this cohort, 223 (58.7 %) of the patients were male. The mean age at the time of PC placement was 65.3 ± 14.2 years of age, and the mean CCI was 3.2 ± 2.1 for all patients. One hundred and twenty-five (32.9 %) patients went on to have a cholecystectomy following PC placement. Comparison of patients who underwent PC followed by surgical intervention revealed that they were significantly younger (p = 0.0054) and had a lower CCI (p < 0.0001) compared to those who underwent PC alone. CONCLUSIONS: PC placement appears to be a viable, long-term alternative to cholecystectomy for the management of biliary disease in high-risk patients. Old and frail patients benefit the most, and in this cohort PC may be the definitive treatment.

Cholecystostomy Treatment in an ICU Population: Complications and Risks.

BACKGROUND: Percutaneous cholecystostomy tube placement has widely been used as an alternative treatment to cholecystectomy, especially in advanced disease or critically ill patients. Reported postprocedural complication rates have varied significantly over the last decade. The goal of this study is to evaluate the safety of percutaneous cholecystostomy tube treatment in critically ill patients. STUDY DESIGN: We performed a retrospective chart analysis of 96 critically ill patients who underwent cholecystostomy tube placement during an intensive care unit (ICU) stay between 2005 and 2010 in a tertiary care center in central Massachusetts. Complications within 72 hours of cholecystostomy tube placement and any morbidity or mortality relating to presence of cholecystostomy tube were considered. RESULTS: A total of 65 male and 31 female patients with a mean age of 67.4 years underwent percutaneous cholecystostomy tube placement during an ICU stay. Sixty-six patients experienced a total of 121 complications, resulting in an overall complication rate of 69%. Fifty-four of these complications resulted from the actual procedure or the presence of the cholecystostomy tube; the other 67 complications occurred within 72 hours of the cholecystostomy procedure. Ten patients died. Tube dislodgment was the most common complication with a total of 34 episodes. CONCLUSIONS: Cholecystostomy tube placement is associated with frequent complications, the most common of which is tube dislodgment. Severe complications may contribute to serious morbidity and death in an ICU population. Complication rates may be underreported in the medical literature. The potential impact of cholecystostomy tube placement in critically ill patients should not be underestimated.

Timing of percutaneous cholecystostomy tube removal: systematic review.

INTRODUCTION: Percutaneous cholecystostomy (PC) is an effective procedure to treat moderate or severe acute cholecystitis (AC) in high-risk patients. The ideal timing of the drainage removal is argued. The aim of this study is to analyze our experience and perform a systematic review about the ideal timing of a percutaneous cholecystostomy (PC) tube removal. EVIDENCE ACQUISITION: A web-based literature search was performed and studies reporting the length of the catheter maintenance were analyzed. A regression analysis between the timing of tube removal and morbidity, mortality and disease recurrence was performed. Patients who underwent PC as definitive treatment of moderate or severe acute cholecystitis at our institution between 2011 to 2015 were analyzed. Clinical and technical success, morbidity, mortality and recurrence rates were retrospectively retrieved from a perspective database. EVIDENCE SYNTHESIS: The systematic review yield to analyze 50 studies. None of them focused exclusively on outcome measures in relation to PC tube duration. The timing of the drain removal varied from 2 to 193 days. Regression analyses showed no correlation between length of tube maintenance and the considered outcomes. We studied 35 patients. The median age was 78 (range 52-94) and 88.5% had an ASA score ≥3. P-POSSUM estimated morbidity was 68.7% (range 34.3-99.0) and mortality was 15.8% (range 1.9-80.2). Clinical success was 97.1%. Procedure-related morbidity was 34.3%: 2 abscess, 1 bleeding, 1 biloma and 8 tube dislodgment. Biliary leakage was not observed. The observed 30-day overall mortality was 11.4%. The median follow-up was 16 months. Recurrence rate was 12.1%. CONCLUSIONS: PC is an effective procedure in high-risk patients with moderate or severe AC. At the moment there is no evidence whether the duration of PC tube may affect outcome.