| Abstract |
PURPOSE: The aim of this study was to evaluate percutaneous cholecystostomy(PC) as a therapeutic method of treatment in patients with acute cholecystitis who are at increased surgical risk. More specifically to evaluate the anatomy of the right upper quadrant, the complications, the time required for tract maturation and the days of hospitalization in order to determine the more suitable puncture route, imaging guιdance, puncture teqnique and appropriate postprocedural imaging strategy. METHODS: In a preliminary anatomical study, theoretical feasibility of transperitoneal and transhepatic PC was investigated in 454 abdominal CT scans that were normal or with conditions that could not affect the position of the liver or colon. Transperitoneal GB puncture was qualitatively judged non-feasible in case of complete interposition of colon or liver between the GB and the anterior abdominal wall and in case of interposed colon in contact with liver. Transhepatic PC was considered modifiable or non-feasible in cases of interposing colon between the liver and the anterior or lateral abdominal wall, in cases of Chilaiditi's syndrome and in over-distended GBs, uncovered by liver parenchyma. Clinical evaluation of PC was based on a series of 63 high surgical risk patients with clinical, laboratory and ultrasonographic evidence of acute cholecystitis. PC was attempted in 31 males and 32 females aged 43-95 years old with acute calculus cholecystitis (44 patients) and acalculous cholecystitis (19 patients). Transperitoneal puncture was attempted in 25 patients and transhepatic in 38 under CT guidance in 28 and US guidance in 35. The Seldinger technique was employed in 21 patients and the Trocar system in 42. Fluoroscopic evaluation of the gallbladder and remaining biliary system patency as well as of the catheter was accomplished by injecting diluted contrast material after 3-5 post-procedural days. Following syringography, the catheter was removed after at least the 14th post-procedural day. RESULTS: Transperitoneal puncture of the gallbladder was non-feasible in 36,4% of the general population. Transhepatic puncture of the gallbladder would have required modification or conversion to transperitoneal puncture in 10% of cases due to either interposing colon (7,3%) or due to incomplete coverage of gallbladder by liver parenchyma (2,7%). In 63 candidates for PC transperitoneal puncture was excluded in 15,9% of patients and transhepatic puncture in 14,3%. PC was technically successful in 59 patients. The procedure was not complete in 4 because of uncooperative patients (n=2) and because of bile peritonitis (n=2). Rapid clinical improvement occurred in 49 patients (77,8%). In 4 successfully and in 2 unsuccessfully punctured patients, resolution occurred gradually. Eight patients (12,7%) died due to persisting sepsis. One patient (1,6%) developed bile peritonitis, was operated and died 2 days later. Five more patients died due to underlying disease despite initial improvement. Early catheter dislodgement / occlusion occurred in 12 patients, 2 of which were operated on. Recurrence of cholecystitis has been noted in 1 patient (5,8%) with acalculus and 8 (17,4%) with calculus cholecystitis while 12 patients have undergone cholecystectomy at a later stage. Eleven out of 15 patients with acalculous cholecystitis and a successfully placed catheter benefited from the procedure (73,3%). There was no statistically significant difference (Ρ>0,005) concerning the occurrence of complications, successful outcome, hospitalization time with regard to different puncture route, method of puncture, imaging guidance and presence of calculi. Cutaneous fistula matured earlier with transhepatic than with transperitoneal PC. CONCLUSION: Percutanous cholecystostomy is a safe, rapid and effective method of treatment of high surgical risk patients with acute cholecystitis. In cases of acalculus cholecystitis it can cure the patient while in cases of calculus cholecystitis it can be a temporary method of stabilizing the patient so that he/she can be operated at a later stage.
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Η απεικονιστικά καθοδηγούμενη διαδερμική χολοκυστιμία στην αντιμετώπιση κρισίμως πασχόντων ασθενών με οξεία χολοκυστίτιδα
