Clinical Audits of Emergency Percutaneous Cholecystostomy in ...

OverviewRADIOLOGY• Background• Percutaneous Cholecystostomy (PCC)• Objectives of Audit• Results• Discussion

BackgroundRADIOLOGY• Acute cholecystitis• Management• Conservative vs. Operative• Cholecystectomy vs. Percutaneous Cholecystostomy• Overseas experience• Technical success rate (97-100%)• Effectiveness (90-94%)• Complication rate (3.3-16%)• Local experience• Li JC, Lee DW, Lai CW, Li AC, Chu DW, Chan AC.Percutaneous cholecystostomy for the treatment of acutecholecystitis in the critically ill and elderly. Hong KongMed J. 2004 Dec;10(6):389-93.

Percutaneous Cholecystostomy(PCC)RADIOLOGYLiverGBChest WallSchematic Diagram of PCC

Percutaneous CholecystostomyRADIOLOGY• Indications:• Critically ill or elderly patients with calculouscholecystitis• Acute acalculous cholecystitis• Local Anesthesia• Techniques• Transhepatic approach• Transperitoneal approach

CholecystogramRADIOLOGY

Percutaneous CholecystostomyRADIOLOGY• Complication:• Bile leakage resulting in peritonitis• Vagal effect of catheter placement (bradycardiaand hypotension)• Hemobilia (usually transient and self-limiting)• Mortality 3-36%

Objectives of AuditRADIOLOGY• To assess the clinical parameters of thepatients undergoing percutaneouscholecystostomy.• To evaluate the technical aspects ofpercutaneous cholecystostomy.• To follow up the patients after percutaneouscholecystostomy.

Material & MethodsRADIOLOGY• Retrospective Review• Selection criteria• Data• All patients who underwent PCC from 01.06.2003to 31.05.2005• retrieved from CMS and RIS

Data CollectionRADIOLOGY• Demographics• Age• Gender• Date & time of procedure• Clinical parameters• Abdominal pain• Body temperature• Hemodynamic Stability• Bilirubin level• WCC• Platelet count• INR• Radiological diagnosis bymodality• Time between radiological examand PCC• Technical parameters• Imaging guidance• Approach• Calibre of puncture needle• Use of Exchange catheter• Size of Fascial dilatros• Drainage catheter used• Anchorage of the catheter• Fentanyl usage• Time of procedure• Result• Technical result• Bile culture• Death• Time between mortality and PCC• Complication• Blood tests after PCC• Duration of hospital stay• Operation (Cholecystectomy)• Time between operation andPCC

DemographicsRADIOLOGY• Total 46 patients (M:F = 22:24)• Mean age = 79.6 years (median = 80.0 years).

Clinical PresentationRADIOLOGYPercentagePain100.0Fever79.3Septic Shock 33.3Elevated WCC78.2Elevated Bilirubin58.70 25 50 75 100

Radiological Diagnosis by ModalityRADIOLOGY

Technical Aspects of PercutaneousCholecystostomyRADIOLOGY• All procedures performed under ultrasoundand fluoroscopic guidance• Transhepatic approach - 34 patients (73.9%)• Transperitoneal approach - 6 patients (13.0%)• Time of procedure (mean = 27minutes)

ResultsRADIOLOGY• Technically successful PCC in 100%• Positive bile culture in 32/45 (71.1%)• Rapid clinical improvement in 41/46 patients(89.1%)• Duration of hospital stay - 15 days (median)• Elective cholecystectomy performed in 11patients (23.9%).

Result - ComplicationRADIOLOGY• Catheter displacement:• 3 patients (6.5%).• 1 Reinsertion• 2 Treated conservatively• Time of occurence• Between 3 days – 1 week in 1patient• > 1 week in 2 patients

Result - MortalityRADIOLOGY• Deaths in 6 patients (10.5%) and all are not related tothe procedure• Uncontrolled sepsis in 2 patients• Patient 1 (M/65)• Refused cholecystectomy• Klebsiella (Resistant to Ampicillin, Cefazolin, CefoxitinCefuroxime)• Given Tazocin, Metronidazole• Patient 2 (M/79)• Disseminated intravascular coagulopathy at presentation• Other medical conditions in 4 patients

RADIOLOGYDiscussion: ComparisonDiscussion: Comparison28%Median22d20%16%(minor)92%100%25Li90%94%90%89.1%ClinicalResponse30166546No. ofPatients90%--3.3%(minor)100%Ito44%-18%18%(1 major)94%Teoh15.3%Mean 15d13.8%No majorones97%Welschbillig23.9%Median15d10.5%6.5%(minor)100%PYNEHElectivecholecystectomyDurationof stayDeathsComplicationTechnicalResultAuthors

ConclusionRADIOLOGY• Our results are comparable with overseas and localdata.• Percutaneous Cholecystostomy is a safe and effectivetreatment of acute cholecystitis with high success andlow complication rates.• It can also minimize the morbidity and mortalityrelating to the complications from emergencyoperation on those critically ill patients, ascholecystectomy can be arranged on an elective basisafter the patient's condition improves.

ReferencesRADIOLOGY• Li JC, Lee DW, Lai CW, Li AC, Chu DW, Chan AC. Percutaneouscholecystostomy for the treatment of acute cholecystitis in the criticallyill and elderly. Hong Kong Med J. 2004 Dec;10(6):389-93.• Welschbillig-Meunier K, Pessaux P, Lebigot J, Lermite E, Aube Ch,Brehant O, Hamy A, Arnaud JP. Percutaneous cholecystostomy forhigh-risk patients with acute cholecystitis. Surg Endosc. 2005Sep;19(9):1256-9. Epub 2005 Jul 14.• Teoh WM, Cade RJ, Banting SW, Mackay S, Hassen AS. Percutaneouscholecystostomy in the management of acute cholecystitis. ANZ J Surg.2005 Jun;75(6):396-8.• Ito K, Fujita N, Noda Y, Kobayashi G, Kimura K, Sugawara T,Horaguchi J. Percutaneous cholecystostomy versus gallbladderaspiration for acute cholecystitis: a prospective randomized controlledtrial. AJR Am J Roentgenol. 2004 Jul;183(1):193-6.