The American Journal of Surgery 183 (2002) 62 66

Laparoscopy

Percutaneous transhepatic cholecystostomy and delayed laparoscopic

cholecystectomy in critically ill patients with acute calculus
cholecystitis
Ram M. Spira, M.D.a, Aviran Nissan, M.D.a, Oded Zamir, M.D.a, Tzeela Cohen, M.D.a,
Scott I. Fields, M.D.b, Herbert R. Freund, M.D.a,*
a
Department of Surgery, Hadassah University Hospital Mount Scopus and Hebrew University-Hadassah Medical School, P.O. Box 24035, Jerusalem
il-91240, Israel
b
Department of Radiology, Hadassah University Hospital Mount Scopus and Hebrew University-Hadassah Medical School, Jerusalem, Israel

Manuscript received February 8, 2001; revised manuscript July 26, 2001

Abstract
Background: The ultimate therapy for acute cholecystitis is cholecystectomy. However, in critically ill elderly patients the mortality of
emergency cholecystectomy may reach up to 30%. Open cholecystostomy performed under local anesthesia was considered to be the
procedure of choice for treatment of acute cholecystitis in high-risk patients. In recent years, ultrasound- or computed tomography
(CT)-guided percutaneous transhepatic cholecystostomy (PTHC) replaced open cholecystostomy for the treatment of acute cholecystitis in
critically ill patients.
Methods: The aim of the present study was to evaluate the results of a 5-year protocol using PTHC followed by delayed laparoscopic
cholecystectomy for the treatment of acute cholecystitis in critically ill patients. We reviewed the charts of 55 patients who underwent PTHC
at the Hadassah University Hospital Mount Scopus during the years 1994 to 1999.
Results: The main indications for PTHC among this group of severely sick and high-risk patients was biliary sepsis and septic shock in 23
patients (42%); and severe comorbidities in 32 patients (58%). The median age was 74 (32 to 98) years, 33 were female and 22 male.
Successful biliary drainage by PTHC was achieved in 54 of 55 (98%) of the patients. The majority of the patients (31 of 55) were drained
transhepaticlly under CT guidance. The rest, (24 of 55) were drained using ultrasound guidance followed by cholecystography for
verification. Complications included hepatic bleeding that required surgical intervention in 1 patient and dislodgment of the catheter in 9
patients that was reinserted in 2 patients. Three patients died of multisystem organ failure 12 to 50 days following the procedure. The
remaining 52 patients recovered well with a mean hospital stay of 15.5 11.4 days. Thirty-one patients were able to undergo delayed
surgery: 28 underwent laparoscopic cholecystectomy of whom 4 (14%) were converted to open cholecystectomy. This was compared with
a 1.9% conversion rate in 1,498 elective laparoscopic cholecystectomies performed at the same time period (P 0.012). Another 3 patients
underwent planned open cholecystectomy, 1 urgent and 2 combined with other abdominal procedures. There was no surgery associated
mortality, severe morbidity, or bile duct injury.
Conclusions: The use of PTHC in critically ill patients with acute cholecystitis is both safe and effective. 2002 Excerpta Medica, Inc.
All rights reserved.

Keywords: Percutaneous cholecystostomy; Acute cholecystitis; Laparoscopic cholecystectomy; Critically ill

Acute calculus cholecystitis is one of the most frequent
emergency admissions to general surgical services with
50% to 70% of cases occuring in elderly patients. Although
early cholecystectomy is considered by many the appropri-
ate treatment for patients with acute cholecystitis it may
* Corresponding author. Tel.: 011-972-2-5844550; fax: 011-972-
2-5323005.
E-mail address: bertifreund@rocketmail.com
carry significant morbidity and mortality in high-risk pa-
tients [13] and in advanced stages of cholecystitis [4].
Others prefer the conservative approach to acute cholecys-
titis using intravenous fluid and antibiotic therapy initially,
and aiming for cholecystectomy to be performed following
full recovery of the patient and adequate preoperative eval-
uation and preparation. The introduction of laparoscopic
cholecystectomy did not change this approach to the patient
with acute cholecystitis, except for the fact that laparoscopic

0002-9610/02/$ see front matter 2002 Excerpta Medica, Inc. All rights reserved.
PII: S 0 0 0 2 - 9 6 1 0 ( 0 1 ) 0 0 8 4 9 - 2
 R.M. Spira et al. / The American Journal of Surgery 183 (2002) 62 66
cholecystectomy for acute cholecyctitis is associated with a
significantly higher conversion rate to open cholecystec-
tomy [511].
Tube cholecystostomy is a procedure intended to decom-
press the acutely inflammed gallbladder in patients unre-
sponsive to medical therapy or for those posing a high
operative risk. In recent years percutaneous cholecystos-
tomy (PTHC) techniques were developed as an alternative
to surgical cholecystostomy for acute cholecystitis [12].
In an attempt to extend the advantages and benefits of
laparoscopic cholecystectomy to high-risk patients with
acute cholecystitis we followed a treatment algorithem that
involved early decompression of the acutely inflamed gall-
bladder by PTHC followed, if possible, by an elective lapa-
roscopic cholecystectomy several weeks or months later.
This is a review of our 5 years of experience with PTHC in
critically ill patients with acute cholecystitis.
Patients and methods
During 1994 to 1999, 55 high-risk patients were treated
by percutaneous cholecystostomy for acute cholecystitis.
These include 33 women and 22 men at a median age of 74
(range 32 to 98) years. The diagnosis of acute cholecystitis
was established by clinical data (history and examination),
laboratory data, and ultrasonographic findings. All patients
were treated according to prospective guidelines which in-
cluded initial treatment with antibiotics, bowel rest and
nasogastric aspiration, intravenous fluids, and analgesics.
Antibiotics were used in all patients and included a combi-
nation of ampicillin and an aminoglycoside. Only in pa-
tients with impaired renal function was the aminoglycoside
replaced by aztreonam. Metronidazole was added in elderly
patients and in diabetics to cover potential anaerobes.
The chart review of all 55 patients who underwent percu-
taneous cholecystostomy focused mainly on the severity of
the gallbladder disease, comorbidities, delay in diagnosis,
interval between diagnosis and PTHC, intensive care
unit (ICU) stay, hospital stay, radiology reports for imaging
and interventional procedures, and interval between chole-
cystostomy and elective cholecystectomy. Operative and
anesthesia reports were searched for operative technique
(laparoscopic, open, or laparoscopic converted to open),
indication for surgery, American Society of Anesthesiolo-
gists (ASA) grade of operative risk, and complications.
Cholecystostomy was performed, following informed
consent, under local anesthesia, by either computed tomog-
raphy (CT) scan or ultrasonography (US) guidance. US-
guided transhepatic cholecystostomy was performed either
bed side at the intensive care unit or at the radiology suite.
An 18F spinal needle was positioned transhepatically in the
gallbladder and bile was aspirated and cultured. The
Seldinger technique was used to place an 8.3F pigtail cath-
eter. When available the location of the cholecystostomy
catheter was verified by fluoroscopy following the injection
63
Table 1
Associated comorbidities in 55 patients with acute cholecystitis
Disease Number of patients
Malignancy 6
Pulmonary 11
Vascular 7
Renal 4
Cardiac 20
Ischemic heart disease 27
Hypertension 22
Diabetes mellitus 18
Ulcer 3
Others 13
Total 131
of water soluble contrast material. Under CT guidance a
22G spinal needle was inserted into the gallbladder, bile was
aspirated and cultured and a 8.3F pigtail catheter was intro-
duced over a guidewire into the gallbladder. Following the
procedure, the patient was rescanned to verify the correct
location of the cholecystostomy catheter.
Analysis of the data was performed using Microsoft
Excel95 for Windows95 and the difference between groups
was calculated using students two-tailed test with the SSPS
statistical package.
Results
Catheter placement
Fifty-seven PTHC procedures were performed in 55 pa-
tients suffering from acute cholecystitis (2 patients had 2
procedures each). During this period a total of 329 patients
were hospitalized on our ward for the treatment of acute
cholecystitis. All 55 patients were considered to be of
extremely high anesthetic or surgical risk due to the com-
bination of their septic state, iresponsive to conservative
management, and complex medical problems (Table 1) pre-
cluding immediate emergency cholecystectomy. Twenty-
nine percent of the patients were at ASA 4; 34.5%, ASA 3;
34.5%, ASA 2; and 2%, ASA 1. Twenty patients were
symptomatic for up to 24 hours prior to admission and were
drained due to the severity of sepsis on admission. Twenty
patients were symptomatic for a median of 4.5 (range 2 to
14) days before admission and were drained for failure of
conservative treatment. In 15 patients the course of disease
was complicated and involved a prolonged in-hospital stay
with misdiagnosis and delay of appropriate of treatment.
Median interval between hospital admission and PTHC in-
sertion was 3 days (range 1 to 30). Among this group of
severely sick and high-risk patients due to the combination
of multiple comorbidities and severe septic process the main
indication for PTHC insertion was severe biliary sepsis with
or without septic shock in 23 patients (42%) and severe
comorbidities in 32 patients (58%).
64 R.M. Spira et al. / The American Journal of Surgery 183 (2002) 62 66

Biliary sepsis was defined by a toxic state characterized

by high fever, high white blood cell count with shift to the
left or sepsis-induced leucopenia, localized right upper ab-
dominal peritonitis, obtundation, and hemodynamic insta-
bility with or without the need for pressor drugs.
Catheter placement was successful in 98.2% (56 of 57).
Fifty-seven cholecystostomies were performed in 55 pa-
tients: 32 CT-guided PTHC (56%), and 25 US-guided
(44%). The earlier procedures were performed mostly under
US guidance with a shift towards CT guidance along the
study period. In later years US-guided PTHC was per-
formed solely for patients in the ICU or patients with im-
paired renal function that would not tolerate intravenous
contrast material. All 55 patients tolerated the procedure
well, the only major complication being a bleeding liver
laceration in an 82-year-old septic patient (1.8%) that was
successfully managed by laparotomy and oversuture of the
bleeding site.

Hospital course
Following PTHC insertion, a rapid clinical improvement
was noticed in the majority of patients (95.7%) within 72
hours (58.7% of patients improved within 24 hours; 78.3%
within 48 hours). This was demonstrated by the resolution
of symptoms and signs and the return of temperature and
white blood cell count to normal levels. The mean time for
clinical improvement was 1.7 days. The median ICU stay
was 4.5 days (range 1 to 50) and the median hospital stay
was 15.5 11.4 days (range 5 to 66). All but 3 patients
were discharged from the hospital. Three patients already
admitted in overwhelming sepsis but without diffuse peri-
tonitis died of multisystem organ failure 12, 45, and 50 days
after the procedure. Inadvertant catheter dislodgment oc-
curred in 9 patients during their hospital stay. Two patients
in whom the dislodgment occurred in the early postproce-
dure days underwent successful reinsertion. The other 7
patients managed well without reinsertion of the PTHC.
Forty-four patients were discharged from the hospital with
cholecystostomy catheters in place, draining into a small
bag.
Follow-up and definitive surgery
All 52 surviving patients were followed as outpatients. In
patients free of symptoms the catheters were eventually
plugged up to 2 months postdischarge. Ten patients had to
be readmitted because of recurrent cholecystitis during the
follow-up period. In these patients the catheter was un-
plugged and drained. These episodes were usually covered
by a short course of intravenous antibiotic therapy. One
patient had to undergo emergency open cholcystectomy
(Fig. 1).
Elective surgery was eventually performed in 30 patients
once their clinical condition was sufficiently stable (median
3.1 [1.5 to 7.0] months postcholecystostomy). Two patients
Fig. 1. Flow chart of outcome in 55 patients with acute cholecystitis
undergoing ultrasonography or computed tomography guided percutaneous
cholecystostomy.
underwent open cholecystectomy combined with closure of
colostomy in 1 and with closure of an enterocutaneous
fistula in the other. Laparoscopic cholecystectomy was at-
tempted in 28 patients, of whom 24 (86%) were successfully
accomplished and 4 (14%) were converted to open chole-
cystectomy (Fig. 1). Our conversion rate for 1,498 elective
laparoscopic cholecystectomies performed during the same
time period was 1.9% (P 0.012). The mean operative time
was 114 45 minutes. All patients recovered well from
surgery with only 1 patient suffering pneumonia as a single
major complication. No perioperative mortality or laparo-
scopic cholecystectomy associated complications were ob-
served. Nonoperated on patients were followed up for a
mean of 13.5 (1 to 42) months after cholecystostomy. Dur-
ing the follow-up period 11 patients died of causes unrelated
to their biliary tract disease. Nine other patients were con-
sidered to pose a prohibitive operative risk or declined
surgery (Fig. 1).
Comments
Acute cholecystitis is a common disease that may carry
the risk of complications like, empyema, gangrene, perfo-
ration, pericholecystitis with abscess formation, peritonitis,
and sepsis. As the incidence of gallbladder disease increases
with age, the proportion of elderly patients with acute cho-
lecystitis and severe systemic comorbidities increases, pos-
ing a high-risk situation for morbidity and mortality. In the
elderly patient cholecystectomy for acute cholecystitis car-
ries an operative mortality of approximately 10% in good
risk patients, which increases threefold in poor risk patients
[13].
 R.M. Spira et al. / The American Journal of Surgery 183 (2002) 62 66
In the prelaparoscopy era cholecystostomy was used for
patients too sick to undergo emergency cholecystectomy,
either because of septic complications that resulted from
severe biliary inflammation and infection or due to the
morbidity of surgery and anesthesia in patients with under-
lying medical comorbidities like diabetes, cardiovascular
disease, renal failure, pulmonary insufficiency, and others.
Laparoscopic cholecystectomy changed little in this re-
spect as we are still dealing with an elderly population [13],
with many and often life-threatening comorbidities (in the
present study median age of our group was 74 years with 2.4
comorbidities per patient), significantly increasing the an-
aesthetic and surgical risk. Moreover, many of these pa-
tients present late and in an advanced septic state, further
increasing surgery associated morbidity and mortality [7,11,
14 17].
Conversion from a laparoscoic to an open procedure is
another consideration. The literature reports conversion
rates in acute cholecystitis to be significantly higher com-
pared with elective laparoscopic cholecystectomy ranging
from 11% to 28% [5 8,11,12,14,15,18 20], and reaching
up to 39% in advanced cholecystitis [15]. An even higher
conversion rate and an increased complication rate after
surgery for acute cholecystitis was reported in patients with
a duration of complaints exceeding 48 to 96 hours [7,11,
14 16]. However, the issue of conversion seems to be of
lesser importance compared to the high morbidity and even
mortality inherent to the removal of the gallbladder in se-
verely sick patients with acute cholecystitis [2123].
Many authors confirmed both efficacy as well as safety
of laparoscopic cholecystectomy in acute cholecystitis
[6,20,24]. However, others pointed out the increased rate of
conversion [9,11,14,15] and a significantly increased rate of
common bile duct injuries [9]. It seems as if a clear line can
be drawn between the results of laparoscopic cholecystec-
tomy for early acute cholecystitis (up to 24 to 72 hours from
the initiation of symptoms) where conversion and compli-
cation rates are comparable to elective surgery or only
moderately increased, and late cholecystitis (symptoms
longer than 48 to 72 hours) where the conversion rate and
morbidity are high [7,11,16,17]. Eldar et al [14] found a
conversion rate of 8% for uncomplicated acute cholecysti-
tis, 12,5% for empyema of the gallbladder, and 40% for
gangrenous cholecystitis. Similarly, the complication rate
rose from 16% in acute cholecystitis to 21% to 22% in
empyema or gangrenous cholecystitis. Compared with early
acute cholecystitis advanced cholecystitis was associated
with significant patient delay and a substantially higher
conversion rate [15].
The obvious advantages of elective laparoscopic chole-
cystectomy influenced some surgeons to abandon the early
surgery approach in favor of the delayed surgery approach.
In the later, patients with acute cholecystitis are being
treated with intravenous fluids and antibiotic therapy, and
surgery is delayed for 6 to 8 weeks after recovery from
acute cholecystitis. This approach found acceptance due to
65
the high conversion rate from laparoscopic to open chole-
cystectomy as well as the higher morbidity, in particular the
increased rate of bile duct injuries in the early surgery
approach.
However, not all patients being treated for acute chole-
cystitis respond to antibiotics and thus might require surgery
to avoid progression of gallbladder inflammation with en-
suing gangrene or perforation at the worst timing possible.
The development of ultrasound and CT-guided percutane-
ous transhepatic cholecystostomy techniques, simplified the
treatment of critically ill acute cholecystitis patients. The
US-guided procedure can be performed even at the bedside
in the ICU. The safety of the procedure and its minimal
invasiveness made it a valid treatment option for patients
with acute cholecystitis who do not respond to conservative
treatment [18,2527]. In the present study PTHC was pre-
dominantly indicated for the combination of severe acute
cholecystitis in patients who are not acceptable candidates
for emergency surgery because of severe comorbidities. In
this group we targeted elderly, critically ill patients with
severe underlying diseases (63.5% of patients at ASA 3 to
4 with 2.4 associated diseases per patient) who were hemo-
dynamically unstable as a result of well-documented acute
cholecystitis, or patients who were initially stable but dete-
riorated or failed to respond within 24 to 48 hours of
intensive conservative measures. Although most of the pa-
tients in the present study were in critical condition at the
time of the procedure, 51 of 55 (93%) were discharged from
the hospital forgoing the need for emergency cholecystec-
tomy and its inherent morbidity and mortality. We encoun-
tered only one major complication of hepatic bleeding that
was successfully treated surgically. With the routine intro-
duction of LC we adopted the delayed surgery policy and in
nonresponding patients we perform PTHC within 24 to 48
hours from admission. The 3-day median interval between
admission and PTHC insertion reflects the group of patients
who were either admitted to the hospital with other critical
conditions and developed cholecystitis during their hospital
course or patients with a delayed diagnosis of acute chole-
cystitis. Our results prove that the percutaneous technique is
safe and that it was effective in 98% of our patients. Al-
though the delayed laparoscopic cholecystectomy conver-
sion rate of 4 of 28 (14%) in this series is high compared to
our elective conversion rate of 1.9%, it is still significantly
lower than the conversion rate for laparoscopic cholecys-
tectomy rates in the acute state in most published series.
Furthermore, we encountered no bile duct injuries or any
other major surgical complications in this group of patients
who underwent delayed elective surgery.
This study confirms the safety and effectiveness of US-
guided or CT-guided percutaneous cholecystostomy for the
initial and interim, or sometimes even definitive treatment
of patients with severe acute cholecystitis who are at high
operative risk for immediate cholecystectomy.
66 R.M. Spira et al. / The American Journal of Surgery 183 (2002) 62 66
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