The incidence of AC increases with age. Surgery in AC cases involving high-risk, geriatric patients may lead to serious morbidity and mortality
3. For these patients
PC can serve as a life-saving procedure, insofar as it provides 98% biliary drainage. Moreover, this procedure can buy time for both the patient and the surgeon in cases where elective surgery is being considered
4, 9, 10. The method was first described by Radder in 1980 in a case of gallbladder empyema
6, and to date, many studies have confirmed the safety and effective-ness of the method.
PC is usually performed under local anesthesia by an invasive radiologist who places a catheter into the gallbladder transhepatically or transperitoneally with the aid of ultrasonography. The more oftenly preferred method is the transhepatic cholecystostomy, where there is a lower chance of a biliary leak. If there is an anatomical misfit or coagulopathy, the catheter can be placed transperitoneally 12. Morbidities related to PC procedures are between 8-44%. Major complications involved with PC procedures include catheter dysfunction, misplacement of the catheter, injuries of the biliary ducts and intracholecystic hemorrhage 11. In all of our cases, transhepatic cholecystostomy was performed and no complications occurred (Figures 3 and 4).
As there is no guideline governing the follow-up care involving the cholecystostomy tube and catheter in cases of PC, the clinics must rely largely on their experience in performing follow-up drainage procedures 7, 11, 13. Kortram et al. 7 stated that the drain sho-uld stay for at least three weeks, at which point the catheter can be pulled out if the cystic duct is observed to be open in the cholecystogram. In the study conducted by Sanjay et al. it was stated that the drain should stay for at least six weeks and then can be pulled if the passage is observed to be open on the cholangiogram 11. Lastly, Cha et al.13 stated that in cases that Show clinical improvement, the passage should be checked with cholecystogram and if the passage is open, the drain should then be clamped and pulled out at the end of the third day in the absence of any clinical findings. In our clinical experience, we believe that the drain should stay for at least three weeks in order for the tract to form and to prevent biliary leaks. Further-more, if the cystic duct is observed to be opened on the cholecystogram taken at the end of third week, the catheter should be clamped and pulled out at the end of the third day. In cases where the cystic duct is blocked, we hold that the drain should be pulled out if there is no hydrops shown on the ultrasonography taken after the drain is clamped. For cases where the biliary duct is shown to be blocked in the cholangiogram, a cholecy-stectomy should be performed; if, however, that is not possible, then the catheter should remain for three more weeks. Biliary blockage was present in the cholan-giogram in 4 of our cases. Only 1 of them had a cho-lecystectomy, while the other 3 were not able to be operated on because of high risk. These 3 patients had their catheters pulled out at the end of the sixth week and were discharged with antibiotic treatment. No problems were encountered during the follow-ups.
One of the more contentious issues for patients who have had a PC involves post-drainage procedures, where it is debated whether or not an elective cho-lecystectomy can be performed 14, 15. In some stu-dies, it is emphasized that an elective cholecy-stectomy should be performed, as there is a higher rate of the recurrence of biliary complications with the pulling of the cholecystostomy tube 5, 15. In contrast, some studies have emphasized that biliary comp-lications are rarely encountered and that to insist on the administra-tion of a cholecystectomy for cases showing high risks associated with the use of anesthesia increa-ses morta-lity and morbidity 13. Morse et al. 16 stated that in the 19 cases where a PC was performed, only 1 of them had a recurrent biliary complication and these complications were able to be managed with conservative medical treatment.
The recurrence rate after PC treatment ranged from 4% to 23% 11, 15-18. The causes of recurrence after removed PC are usually calcinous cholecystitis, early removal of PC, inadequate medical treatment of cho-lecystitis attack. There is not a certain consensus for treatment of recurrence cholecystitis after removed PC. There are some controversial treatment approaches for recurrence cholecystitis including medical treatment, repeated insertion of PC, early cholecystectomy, inter-val cholecystectomy. Conservative treatment options are frequently recommended because of high comorbi-dity by ASA (American Society of Anesthesiologists). In a study on the PC for AC conducted by Sanjay et al 11, they reported that 13/53 (22%) patients readmit-ted with recurrent cholecystitis during follow up of which 7 (54%) had a repeated PC. In a study on the AC in the elderly conducted by McGillicuddy et al. 17, they suggested that medical management, with interval cholecystec-tomy only for recurrent AC, might be appropriate in selected patients. In a study on the PC for AC in patients with high comorbidity and reevalua-tion of treatment efficacy conducted by Chang et al. 18, they reported that a temporary PC could be a first-line treatment for AC without interval cholecystec-tomy.
In the 22 cases of our study, 18 had the catheter pulled out and did not have a cholecystectomy because of high anesthesia risk, and 4 had a cholecystectomy after the acute condition was remedied. 2 of the 4 patients who performed cholecystectomy were calculous cholecystitis and others were acalculous cholecystitis and perforated cholecystitis. The patient with perfora-ted cholecystitis underwent operation on the 7th day of medical treatment without another PC tube. Despite medical treatment and PC, these patients did not heal in terms of clinical, laboratory and imaging parameters, and cholecystectomy performed. Patients who had a cholecystectomy usually had treatable accompanying conditions; 1 of them had thrombocytopenia related to chronic ITP and the other 3 were on anticoagulant medicine. A cholecystectomy was performed on these patients after the risk for elective surgery was minimized, and no complications were seen. No recurrent biliary complications were observed. In present study, the one year recurrence rate was 5/22 (22%) after PC treatment and it is similar to the literature. The approp-riate antibiotics were applied and with stopping of oral feeding these patients were discharged with healing. In patients with recurrent cholecystitis, cholecystectomy or repeat PC was not performed.
There are some limitations in our study. Firstly, our study is a retrospective observational study and as such, we were only able to establish an association, rather than relation between independent and outcome variables. Secondly, number of patients was low in the present study and thirdly, we evaluated only our hospital’s data, the recurrence rate might be underes-timated because patients would receive treatment for recurrence at other hospitals.
As a low cost, quickly effective, time saving treatment method with low complication rates, PC can be used as a temporary or definitive treatment method for high-risk geriatric patients with AC. The patient should be reevaluated after the acute condition settles, and the decision to perform a definitive treatment should only be made after a risk evaluation has been done for the administration of anesthesia.
)
)
)
)
)
)