NEW YORK (Reuters Health) – Patients who had percutaneous drainage for acute cholecystitis, instead of cholecystectomy, had longer recoveries, more morbidity, and a trend toward lower survival in a retrospective study.
Percutaneous cholecystostomy “should be reserved for patients with prohibitive risks for surgery,” the researchers concluded in their report this month in Archives of Surgery.
Dr. Kamal M. F. Itani, with the Veterans Affairs Boston Healthcare System in West Roxbury, Massachusetts, and colleagues explain that percutaneous cholecystostomy is considered a safe alternative for elderly or critically ill patients and may be indicated for severe cases. “This treatment modality, however, is not without a unique spectrum of complications,” they note.
To compare outcomes between percutaneous cholecystostomy and cholecystectomy, the team reviewed their 10-year experience treating 201 patients with acute cholecystitis at their VA center. Fifty-one patients had percutaneous cholecystostomy using the transhepatic Seldinger technique. The other 150 patients underwent cholecystectomy.
The cholecystostomy patients were older than the cholecystectomy patients (70 vs 65 years) and had higher alkaline phosphatase levels (198 vs 140 U/L). They also had more comorbidities (Charlson index scores 3.1 vs 1.0), and were more likely to be in American Society of Anesthesiologists (ASA) class 3 or 4 (73.6% vs 68.7%).
On multivariate analysis, a Charlson comorbidity score of 4 or higher was the only independent predictor of percutaneous cholecystostomy being performed rather than cholecystectomy.
“These results indicate that our patients’ comorbid conditions and general medical risks for surgery were more important than the duration or severity of acute cholecystitis in determining their treatment,” the authors comment.
ICU stays were longer for cholecystostomy (5.9 vs 2.3 days, p=0.008), as were overall hospital stays (20.7 vs 12.1 days, p<0.001).
There were more complications per patient after cholecystostomy vs cholecystectomy (2.9 vs 1.9; p=0.01), and readmission rates were higher at 31.4% vs 13.3% (p=0.006), Dr. Itani and colleagues found.
The hazard ratio for death after percutaneous cholecystostomy versus cholecystectomy was 1.75, but this did not reach statistical significance. The only independent predictor of post-procedure death over time was again a Charlson comorbidity index score of 4 or higher.
The team concludes that percutaneous cholecystostomy should be reserved for patients with very high surgical risks, regardless of the severity of acute cholecystitis.
The author of a related commentary, Dr. Rocco Orlando III at Hartford Hospital and the University of Connecticut School of Medicine, notes that a trial comparing the two procedures in high-risk surgical patients is planned. “Until then, the nuances of surgical decision-making in this patient population remain difficult and require thoughtful clinical judgment,” Dr. Orlando said.
Arch Surg 2012;147:416-422.