Percutaneous cholecystostomy for acute cholecystitis: are we following current guidelines and evidence?

Author(s):
Andrea Spota; Amir Hassanpour; Eran Shlomovitz;
David Gomez; Eisar Al-Sukhni

Background:

Tokyo guidelines 2018 recommend percutaneous gallbladder drainage in patients with Charlson Comorbidity Index (CCI)≥6 + mild/moderate acute cholecystitis (AC) or CCI≥4 + severe AC. However, the multicenter CHOCOLATE RCT (2018) found increased major complications, length of stay (LOS), and recurrent biliary disease with percutaneous cholecystostomy (PC) versus surgery in high risk patients.

Hypothesis:

PCs are being overused in our population and some patients undergoing PC are suitable for early cholecystectomy.

Methods:

A retrospective matched cohort study was performed. Patients admitted through the emergency department who underwent PC for AC from 2018 to 2023 were identified. Patients who underwent cholecystectomy in the same period were identified, matched 1 to 1 for age range and AC severity (defined as mild/moderate/severe following Tokyo Guidelines). Due to lack of severe and >80 year old cases who underwent a cholecystectomy, such cases were excluded from this comparative analysis. Frailty was measured as a 5item modified Frailty Index (5mFI)≥2.

Results:

148 of 1064 patients with AC underwent PC placement (13.9%) and were compared with 103 matched patients who underwent cholecystectomy. 85% of PCs were placed in patients with mild/moderate AC, 55% of which were in patients <80 years. After excluding severe cases and patients ≥80 years old, we compared 82 PCs to 82 cholecystectomies. The majority of patients with mild/moderate AC receiving PC were functionally independent (71%) and non-frail (5mFI<2 in 57%); median CCI was 4. Patients receiving PC had longer LOS (8 vs 2 days, p<0.001), more complications (31% vs 10%, p=0.002) and deaths (9% vs 0, p=0.007), and higher need for discharge to nursing/rehab facilities (15% vs 1%, p=0.002) and readmission (23% vs 6%, p=0.001) than surgery patients. PCs were inserted in accordance with Tokyo guidelines in only 28% of cases. 19% of PC recipients underwent subsequent cholecystectomy; patients in whom PC was placed outside of Tokyo recommendations were significantly more likely to undergo subsequent cholecystectomy (29% vs 3%, p<0.001). Compliance with guidelines was not related to attending surgeon subspecialty or years of experience.

Conclusions:

A majority of patients undergoing PC insertion at our tertiary care center can potentially undergo cholecystectomy safely if guideline recommendations are considered. A more objective approach to patient selection for PC may be indicated to reduce overuse of this technique.