24th European Congress on Surgical Infection, 26th May, Leon.

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.

• 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?

Introduction

24th European Congress on Surgical Infection, 26th May, Leon.

• 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

Objectives

24th European Congress on Surgical Infection, 26th May, Leon.

• 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

Material and methods

24th European Congress on Surgical Infection, 26th May, Leon.

Results

Epidemiological data

n 35

Age (y) 81±10

Gender M (17); F (18)

ASA III (15); IV (19); V (1)

Duration catheter (d)

15±14

Calculous cholecystitis

Yes (31); No (4)

24th European Congress on Surgical Infection, 26th May, Leon.

Results

Biliary cultures: Positive (25) Negative (8) Not done (2)

Polimicrobial (16) Monomicrobial (9)

Biliary culture results

24th European Congress on Surgical Infection, 26th May, Leon.

Adequacy of treatment

Positivity of biliary culture: 25

21 antibiogram; 4 mixed flora

Antibiothic treatment

Piperacillin-Tazobactam 23

Carbapenems 6

Carbapenems+glycopeptids 2

Other 4

Results

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.

Clinical outcome

Results

n=35

9 Bad

1 alive (1surg)

8 exitus

2 technique related

6 non-technique related (1 surg)

•Clinical efficacy: 74% (26/35)

Major complications related to technique : 5.7% (2/35) 1 gallbladder perforation; 1 bleeding hepatic surface

26 Good

24th European Congress on Surgical Infection, 26th May, Leon.

Surgical requirements

Results

19 no recurrence

5 recurrence

2 exitus (non-biliary)

3 alive (3 surg)

2 exitus (2 ab’s)

• Surgical requirements : 19 % (5/26)

Recurrence of acute cholecystitis: 19% (5/26)

17 alive (2 surg)

26 Good

24th European Congress on Surgical Infection, 26th May, Leon.

Comparison of good and bad primmary outcome

Good (n=26)

Bad (n=9)

p

Epid

em

iolo

gic

s

Age (y) 7810 857 0.08

(N.S.)

ASA III (14)

IV (12)

III (1) IV (7) V (1)

0.07

(N.S.)

Vita

l sig

ns

SBP (Hg mm) 12321 11928 N.S.

Heart rate (BPM) 88.614.9 87.224.5 N.S.

Temperature (ºC) 37.00.7 37.01.2 N.S.

Results

Patients with bad outcome showed a tendency of being older and having a more advanced ASA classification

24th European Congress on Surgical Infection, 26th May, Leon.

Comparison of good and bad primmary outcome

Results

Good (n=26)

Bad (n=9)

p

Blo

od a

naly

sis

WCC (/mL) 163886987 156335811 N.S.

C-reactive protein (mg/L)

20789 26898 0.09 (N.S.)

Total bilirrubine (mg/dL)

1.61.8 5.18.2 0.04*

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.

• 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

Conclusions

24th European Congress on Surgical Infection, 26th May, Leon.