Percutaneous Cholecystostomy: The 2013 Tokyo Guidelines and the Expanding Role of Interventional Radiology in the Management of Cholecystitis
22 March 2018 (online)
Purpose Percutaneous cholecystectomy tube (PCT) placement has traditionally served as a temporizing measure to bridge the comorbid patient presenting with acute cholecystitis and/or acute cholangitis to the current mainstay definitive treatment of cholecystectomy. While criteria outlined by the 2013 Tokyo Guidelines have resulted in a rise in PCT placements, there is lack of a definitive treatment plan should these patients forego surgery due to excessive perioperative risk.
Materials and Methods A total of 147 patients (67 females and 80 males; average age 64.4 years, range 22–91 years, standard deviation [SD] 16.0 years) received a PCT at our institution from February 2011 to February 2016 and were retrospectively analyzed. Patient endpoints were cholecystectomy (laparoscopic, conversion to open, or open), tube removal, mortality, and loss to follow-up.
Results Of the 147 patients, 62 (42.2%) received a cholecystectomy (46 [74.2%] laparoscopic, 10 [16.1%] conversion to open, and 6 [9.7%] open); 22 (15.0%) expired with the tube in place; 21 (14.3%) had the tube removed as definitive treatment; 7 (4.8%) continued indefinite tube management; and 35 (23.8%) were lost to follow-up.
Conclusion Currently, general surgery manages patients clinically after PCT placement with minimal interventional team involvement. While a portion of these patients will be bridged to surgery, some remain too high risk to undergo cholecystectomy. In our hospital, the conversion to open rate for cholecystitis patients exceeds reported averages of 6.1 to 10%.1 Due to the severity of these patients’ chronic comorbidities, there is a need for closer clinical management of their PCTs and alternative definitive treatment options. Interventionalists are uniquely positioned to take on a primary management role with this population. Definitive management has been concept proven including criteria for catheter removal, utilizing fluoroscopic and endoscopic stone removal, as well as gallbladder ablation.2–4 However, integrating interventionalists as part of an interdisciplinary treatment algorithm for patients suffering from acute cholecystitis needs to be addressed.