Patient outcomes after treatment with percutaneous cholecystostomy for biliary sepsis

Introduction Acute cholecystitis is among the most common general surgical presentations. There is a cohort of patients who develop systemic sepsis and complications of acute cholecystitis. These patients are often elderly and co-morbid. Conservative management with percutaneous cholecystostomy has been shown to be a safe and effective management option in the acute setting. However, there is currently no consensus for the further management of these patients. In particular, there is a paucity of data on readmission rates and subsequent operative or non-operative management. Methods A retrospective study was carried out of patients treated with a percutaneous cholecystostomy for biliary sepsis over a three-year period in a UK teaching hospital. Outcome measures were subsequent operative or conservative management, conversion rates, operative complications and readmission rates. Results Twenty-five patients had a percutaneous cholecystostomy for the treatment of acute biliary sepsis. The median follow-up duration was 35 months. Thirteen patients (52%) had operative treatment. In the operative group, 6/13 had a laparoscopic cholecystectomy, 2/13 had a planned open cholecystectomy, 2/13 had abandoned procedures and 3/13 had a converted procedure. Complications in the operative group included: postoperative mortality (1/13), common bile duct injury requiring drainage and endoscopic stenting (1/13) and one patient required readmission with recurrent pain. In the non-operative group, 5/12 patients were readmitted with biliary sepsis, 5/12 had no readmissions, 1/12 died in the community and 1/12 was readmitted with biliary colic. Conclusions Percutaneous cholecystostomy is a recognised treatment modality for elderly, co-morbid patients with biliary sepsis. Nevertheless, the readmission rate in this group is relatively high at 5/12 (42%). Patients who undergo subsequent operative management have a conversion rate of 3/13 (23%) and a significant complication rate of 2/13 (15%). The further management of patients having undergone percutaneous cholecystostomy requires careful consideration on an individual case basis. The P-POSSUM (Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) may aid decision making.

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839 Patterns of Management of Acute Cholecystitis during the COVID 19 Pandemic

British Journal of Surgery ◽

10.1093/bjs/znab259.480 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

B Brown ◽

R Varley ◽

E Reynolds ◽

S Galloway

Keyword(s):

Acute Cholecystitis ◽

Conservative Management ◽

Primary Outcome ◽

Operative Management ◽

Pulmonary Complications ◽

Biliary Complications ◽

Readmission Rates ◽

Appreciable Increase ◽

Pp Wave ◽

Poor Outcomes

Abstract Aim The poor outcomes described by CovidSurg in patients with Covid-19 undergoing surgical intervention and the unknown safety of laparoscopic surgery initially led to increased conservative management in acute cholecystitis (AC). As the number of cases continues to rise, we aim to assess how the coronavirus pandemic has affected our service and adherence to AUGIS guidelines. Method We retrospectively analysed all adult admissions with radiologically confirmed AC from defined 2-month periods (pre-pandemic (PP), wave-1 (W1) and wave-2 (W2)) at an acute general surgical service without dedicated hot gallbladder lists where the prevalence of coronavirus has remained high throughout. Primary outcome was rate of index admission (acute) cholecystectomy. Results 93 patients were included in total (PP 35, W1 33, W2 24). Demographic details were similar across all groups. Tokyo grade I (mild) cholecystitis was more commonly admitted PP (63.9% versus 48.5% and 50.0%). Conservative management was trialed in 91.7%, 100.0% and 62.5% and failed in 18.2%, 21.2% and 21.1%. Cholecystectomy rates were 13.9%, 12.1% and 29.2%. Increased use of CT in W1 has returned to PP imaging pattern in W2. 30-day readmission rates were 5.6%, 18.2% and 4.2%. Two patients in W1 tested positive for Covid-19 and were managed conservatively. No post-operative pulmonary complications were recorded and no difference in biliary complications was observed. Conclusions Operative management of AC as per AUGIS guidelines during the pandemic in Covid-19 negative patients is safe and improves outcomes compared to conservative management with no appreciable increase in biliary complications.

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