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Cholecystostomy in elderly patients
1. Ultrasonographic percutaneous cholecystostomy as a definitive
treatment for acute cholecystitis in the elderly high risk patients
Montserrat Juvany, Mireia Amillo, Núria Rosón*,
Xavier Guirao, Miquel Casal, Esther Nve, Josep
Maria Badia.
Hospital General de Granollers, Barcelona. Spain.
*Radiological Department.
24th European Congress on Surgical Infection, 26th May, Leon.
2. Introduction
• LAPAROSCOPIC CHOLECYSTECTOMY is the gold standard
treatment of acute cholecystitis (mortality rate=0-0.8%)
• However, in the elderly high risk patients the mortality rate of
cholecystectomy is 14-30% and even 77% in ASA IV
• In the elderly high risk patients, ultrasound guided cholecystostomy
(described by Radder, 1980) is likely to be a good option. But, will
this patients require a surgical intervention afterwards?
24th European Congress on Surgical Infection, 26th May, Leon.
3. Objectives
• To evaluate in the elderly high
risk patients with acute
cholecystitis treated by
ultrasound guided
cholecystostomy:
1. Clinical efficacy of the
technique (complications
related)
2. Need of surgery after the
episode of acute
cholecystitis
24th European Congress on Surgical Infection, 26th May, Leon.
4. Material and methods
• Retrospective study from September 2005 until September
2010 (5 years)
• Inclusion of all patients with acute cholecystitis treated by
ultrasound guided cholecystostomy during this period
• Collected data:
– age, gender, ASA
– duration catheter, calculous cholecystitis
– SIRS parameters and blood analysis (diagnosis)
– biliary cultures results
– antibiothic adequacy
• Main variables:
– clinical outcome (first 30 days)
– surgical requirement (medium follow-up of 16 weeks)
• Comparison of patients with good and bad primmary outcomes
24th European Congress on Surgical Infection, 26th May, Leon.
5. Results
Epidemiological data
n 35
Age (y) 81±10
Gender M (17); F (18)
ASA III (15); IV (19); V (1)
Duration 15±14
catheter (d)
Calculous Yes (31); No (4)
cholecystitis
24th European Congress on Surgical Infection, 26th May, Leon.
6. Results
Biliary culture results
Biliary cultures: Positive (25) Negative (8) Not done (2)
Polimicrobial (16) Monomicrobial (9)
24th European Congress on Surgical Infection, 26th May, Leon.
7. Results
Adequacy of treatment
Positivity of biliary culture: 25 Antibiothic treatment
21 antibiogram; 4 mixed flora Piperacillin-Tazobactam 23
Carbapenems 6
Carbapenems+glycopeptids 2
Other 4
Adequacy of treatment: 90%
(19/21)
Reasons for inadequacy: E.coli and enterococcus R to PipTazo
24th European Congress on Surgical Infection, 26th May, Leon.
8. Results
Clinical outcome
n=35
26 9
Good Bad
8 exitus 1 alive
(1surg)
2 technique 6 non-technique
related related (1 surg)
•Clinical efficacy: 74% (26/35)
Major complications related to technique : 5.7% (2/35)
1 gallbladder perforation; 1 bleeding hepatic surface
24th European Congress on Surgical Infection, 26th May, Leon.
9. Results
Surgical requirements
26
Good
19 5
no recurrence recurrence
17 alive 2 exitus 3 alive 2 exitus
(2 surg) (non-biliary) (3 surg) (2 ab’s)
• Surgical requirements : 19 % (5/26)
Recurrence of acute cholecystitis: 19% (5/26)
24th European Congress on Surgical Infection, 26th May, Leon.
10. Results
Comparison of good and bad primmary outcome
Good Bad p
(n=26) (n=9)
Age (y) 7810 857 0.08
Epidemiologics Vital signs
(N.S.)
ASA III (14) III (1) 0.07
IV (12) IV (7)
V (1) (N.S.)
SBP (Hg mm) 12321 11928 Patients with bad outcome
N.S.
showed a tendency of being
Heart rate (BPM) 88.614.9 87.224.5 older and having a more
N.S.
advanced ASA classification
Temperature (ºC) 37.00.7 37.01.2 N.S.
24th European Congress on Surgical Infection, 26th May, Leon.
11. Results
Comparison of good and bad primmary outcome
Good Bad p
(n=26) (n=9)
WCC (/mL) 163886987 156335811 N.S.
Blood analysis
C-reactive protein 20789 26898 0.09
(mg/L) (N.S.)
Total bilirrubine 1.61.8 5.18.2 0.04*
(mg/dL)
They showed a tendency of having higher
levels of CRP
Total bilirrubine was higher (suggesting
associated cholangitis as a marker of worst
prognosis)
24th European Congress on Surgical Infection, 26th May, Leon.
12. Conclusions
• Ultrasonographic percutaneous cholecystostomy is the technique of
choice for acute cholecystitis in the elderly high risk patients (74%
of clinical efficacy)
• It is a definitive treatment in 81% of the patients with good
primary outcome
• High levels of total bilirrubine at the moment of diagnosis are
associated with bad primmary outcome
24th European Congress on Surgical Infection, 26th May, Leon.