24th European Congress on Surgical Infection, 26th May, Leon. Ultrasonographic percutaneous cholecystostomy as a definitive treatment for acute cholecystitis in the elderly high risk patients Montserrat Juvany, Mireia Amillo, Núria Rosón*, Xavier Guirao, Miquel Casal, Esther Nve, Josep Maria Badia. Hospital General de Granollers, Barcelona. Spain. *Radiological Department.
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24th European Congress on Surgical Infection, 26th May, Leon.
Ultrasonographic percutaneous cholecystostomy as a definitive
treatment for acute cholecystitis in the elderly high risk patients
24th European Congress on Surgical Infection, 26th May, Leon.
• LAPAROSCOPIC CHOLECYSTECTOMY is the gold standard
treatment of acute cholecystitis (mortality rate=0-0.8%)
• However, in the elderly high risk patients the mortality rate of
cholecystectomy is 14-30% and even 77% in ASA IV
• In the elderly high risk patients, ultrasound guided cholecystostomy
(described by Radder, 1980) is likely to be a good option. But, will
this patients require a surgical intervention afterwards?
Introduction
24th European Congress on Surgical Infection, 26th May, Leon.
• To evaluate in the elderly high
risk patients with acute
cholecystitis treated by
ultrasound guided
cholecystostomy:
1. Clinical efficacy of the
technique (complications
related)
2. Need of surgery after the
episode of acute
cholecystitis
Objectives
24th European Congress on Surgical Infection, 26th May, Leon.
• Retrospective study from September 2005 until September 2010 (5 years)
• Inclusion of all patients with acute cholecystitis treated by ultrasound guided cholecystostomy during this period
• Collected data:
– age, gender, ASA
– duration catheter, calculous cholecystitis
– SIRS parameters and blood analysis (diagnosis)
– biliary cultures results
– antibiothic adequacy
• Main variables:
– clinical outcome (first 30 days)
– surgical requirement (medium follow-up of 16 weeks)
• Comparison of patients with good and bad primmary outcomes
Material and methods
24th European Congress on Surgical Infection, 26th May, Leon.
Results
Epidemiological data
n 35
Age (y) 81±10
Gender M (17); F (18)
ASA III (15); IV (19); V (1)
Duration catheter (d)
15±14
Calculous cholecystitis
Yes (31); No (4)
24th European Congress on Surgical Infection, 26th May, Leon.
Results
Biliary cultures: Positive (25) Negative (8) Not done (2)
Polimicrobial (16) Monomicrobial (9)
Biliary culture results
24th European Congress on Surgical Infection, 26th May, Leon.
Adequacy of treatment
Positivity of biliary culture: 25
21 antibiogram; 4 mixed flora
Antibiothic treatment
Piperacillin-Tazobactam 23
Carbapenems 6
Carbapenems+glycopeptids 2
Other 4
Results
Adequacy of treatment: 90% (19/21)
Reasons for inadequacy: E.coli and enterococcus R to PipTazo
24th European Congress on Surgical Infection, 26th May, Leon.
Clinical outcome
Results
n=35
9 Bad
1 alive (1surg)
8 exitus
2 technique related
6 non-technique related (1 surg)
•Clinical efficacy: 74% (26/35)
Major complications related to technique : 5.7% (2/35) 1 gallbladder perforation; 1 bleeding hepatic surface
26 Good
24th European Congress on Surgical Infection, 26th May, Leon.
Surgical requirements
Results
19 no recurrence
5 recurrence
2 exitus (non-biliary)
3 alive (3 surg)
2 exitus (2 ab’s)
• Surgical requirements : 19 % (5/26)
Recurrence of acute cholecystitis: 19% (5/26)
17 alive (2 surg)
26 Good
24th European Congress on Surgical Infection, 26th May, Leon.
Comparison of good and bad primmary outcome
Good (n=26)
Bad (n=9)
p
Epid
em
iolo
gic
s
Age (y) 7810 857 0.08
(N.S.)
ASA III (14)
IV (12)
III (1) IV (7) V (1)
0.07
(N.S.)
Vita
l sig
ns
SBP (Hg mm) 12321 11928 N.S.
Heart rate (BPM) 88.614.9 87.224.5 N.S.
Temperature (ºC) 37.00.7 37.01.2 N.S.
Results
Patients with bad outcome showed a tendency of being older and having a more advanced ASA classification
24th European Congress on Surgical Infection, 26th May, Leon.
Comparison of good and bad primmary outcome
Results
Good (n=26)
Bad (n=9)
p
Blo
od a
naly
sis
WCC (/mL) 163886987 156335811 N.S.
C-reactive protein (mg/L)
20789 26898 0.09 (N.S.)
Total bilirrubine (mg/dL)
1.61.8 5.18.2 0.04*
They showed a tendency of having higher levels of CRP
Total bilirrubine was higher (suggesting associated cholangitis as a marker of worst prognosis)
24th European Congress on Surgical Infection, 26th May, Leon.
• Ultrasonographic percutaneous cholecystostomy is the technique of choice for acute cholecystitis in the elderly high risk patients (74% of clinical efficacy)
• It is a definitive treatment in 81% of the patients with good primary outcome
• High levels of total bilirrubine at the moment of diagnosis are associated with bad primmary outcome
Conclusions
24th European Congress on Surgical Infection, 26th May, Leon.