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Eren Berber, MD; Kristen L. Engle, MD; Andreas String, MD; Adella M. Garland, MD; George Chang, MD; James Macho, MD; Jeffrey M. Pearl, MD; Allan E. Siperstein, MD

Arch Surg. 2000;135:341-346.

Hypothesis  Tube cholecystostomy followed by interval laparoscopic cholecystectomy is a safe and efficacious treatment option in critically ill patients with acute cholecystitis.

Design  Retrospective cohort study within a 4-year period.

Setting  University hospital.

Patients  Of 324 patients who underwent laparoscopic cholecystectomy, 65 (20%) had acute cholecystitis; 15 of these 65 patients (mean age, 75 years) underwent tube cholecystostomy.

Intervention  Thirteen patients at high risk for general anesthesia because of underlying medical conditions underwent percutaneous tube cholecystostomy with local anesthesia. Laparoscopic tube cholecystostomy was performed on 2 patients during attempted laparoscopic cholecystectomy because of severe inflammation. Interval laparoscopic cholecystectomy was attempted after an average of 12 weeks.

Main Outcome Measures  Technical details and clinical outcome.

Results  Prompt clinical response was observed in 13 (87%) of the patients after tube cholecystostomy. Twelve patients (80%) underwent interval cholecystectomy. Laparoscopic cholecystectomy was attempted in 11 patients and was successful in 10 (91%), with 1 conversion to open cholecystectomy. One patient had interval open cholecystectomy during definitive operation for esophageal cancer and another had emergency open cholecystectomy due to tube dislodgment. Two patients (13%) had complications related to tube cholecystostomy and 2 patients died from sepsis before interval operation. One patient died from sepsis after combined esophagectomy and cholecystectomy. Postoperative minor complications developed in 2 patients. At a mean follow-up of 16.7 months (range, 0.5-53 months), all patients were free of biliary symptoms.

Conclusions  Tube cholecystostomy allowed for resolution of sepsis and delay of definitive surgery in selected patients. Interval laparoscopic cholecystectomy was safely performed once sepsis and acute infection had resolved in this patient group at high risk for general anesthesia and conversion to open cholecystectomy. Just as catheter drainage of acute infection with interval appendectomy is accepted in patients with periappendiceal abscess, tube cholecystostomy with interval laparoscopic cholecystectomy should have a role in the management of selected patients with acute cholecystitis.

From the Department of General Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio (Drs Berber and Siperstein); and the Department of Surgery, University of California, San Francisco, Mount Zion Medical Center (Drs Engle, String, Garland, Chang, Macho, and Pearl).

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