Perforation as a cause of failure in the conservative treatment of acute cholecystitis: Is percutaneous cholecystostomy a sufficient treatment?

Purpose: To evaluate the effi cacy and safety of percutaneous cholecystostomy in acute cholecystitis cases with high surgical risk that were treated conservatively and developed perforation. Materials and Methods: Between July 2013 and May 2018, 20 acute cholecystitis cases with high surgical risk who underwent conservative treatment and presented with perforation were included in the study. The patients diagnosed with acute cholecystitis based on clinical, laboratory and ultrasonography at the time of presentation received conservative treatment. Upon development of perforation, Percutaneous Cholecystostomy (PC) was performed. Results: After 3.65(2-8) days of conservative treatment, the patients with no improvement in clinical and/or laboratory fi ndings were considered to have complicated cholecystitis and underwent additional imaging procedures. In 20 patients, gallbladder perforation was observed, and a total of 22 catheters were placed. During the procedure, the drainage catheter was successfully inserted in all patients with a technical success rate of 100%. One (5%) patient that was intubated, classifi ed as ASA V, and had grade III cholecystitis and septic shock, died three days after the procedure. Clinical success was calculated as 95%. In addition, two (10%) patients had catheter dislocation as late, minor complications. Conclusions: For the treatment of gallbladder perforations that may develop during the conservative treatment of acute cholecystitis and result in signifi cant mortality and morbidity rates, PC is an effective and safe treatment method, especially in high surgical risk patients. Research Article Perforation as a cause of failure in the conservative treatment of acute cholecystitis: Is percutaneous cholecystostomy a suffi cient treatment? Omur Balli* Department of Interventional Radiology, Izmir Katip Celebi University, Ataturk Training and Research Hospital, 35360, Izmir, Turkey Received: 21 September, 2019 Accepted: 31 October, 2019 Published: 01 November, 2019 *Corresponding author: Omur Balli, MD, Department of Interventional Radiology, Izmir Katip Celebi University, Ataturk Training and Research Hospital, 35360, Izmir, Turkey, Tel: +90 530 284 03 54; Fax: +90 232 243 15 30; E-mail:


Introduction
Acute cholecystitis is one of the most common surgical emergencies [1]. Today, conservative methods, Percutaneous Cholecystostomy (PC) and surgery can be applied to treat this condition. Early surgery, especially Laparoscopic Cholecystectomy (LC) is the fi rst choice and defi nitive treatment for indicated cases. However, conservative methods and/or percutaneous methods are preferred in high-risk cases that are not suitable for surgery. The main factors to be considered in treatment to are age and comorbidities of the patient, the associated Charlson Comorbidity Index (CCI), American Society of Anesthesiologists Physical Status Classifi cation (ASA-PS) score and Acute Cholecystitis Severity Grading (ACSG), and other factors, such as the time between the onset of the event and presentation to the hospital [2][3][4].
Conservative treatment, particularly preferred in cases with high risk of surgical morbidity and mortality, is a method involving the use of antibiotics or fl uid and electrolyte support without antibiotics, and despite conservative treatment, patients may develop complications and the gallbladder may progress to perforation [5,6]. In case of no clinical improvement during conservative treatment, PC or emergency surgery can be performed [7,8]. Nearly 20% of acute cholecystitis cases require emergency surgery due to perforation or gangrenous cholecystitis [9]. However, according to the latest data, the rate of perforation has decreased with the advances in diagnostic tests leading to the identifi cation of symptomatic cholelithiasis and increased number of associated elective gallbladder operations, as well as the improvements in antibiotic treatment [10][11][12][13]. In early publications, the risk of mortality is reported to be high, reaching 42%. Although the mortality rate remains treatment? J Surg Surgical Res 5(2): 087-092. DOI: https://dx.doi.org/10.17352/2455-2968.000080 high, it is now generally lower than 20% with the improvement of intensive care conditions and increased availability of anesthesia [14,15].
Different studies have evaluated the effi cacy and safety of PC as an alternative to surgery in cases presenting with perforated gallbladders at the time of hospital admission [6,16].
The aim of the current study was to investigate the effi cacy and safety of PC in patients who were initially diagnosed with uncomplicated acute cholecystitis, underwent conservative treatment due to high surgical risk, and developed perforation during the follow-up.

Study design and patient population
This retrospective study was approved by the local ethics committee, and informed consent was obtained from all participants before clinical procedures were performed. did not agree to the surgical procedure. Conservative treatment was initiated for the patients, and when perforation developed, their consent was obtained to perform PC.
Tokyo 2013 criteria were used in the diagnosis of acute cholecystitis [17]. All patients underwent an ultrasonography (US) examination at admission and were found to have an increased thickness of the gallbladder wall, gallbladder stones, and hydrops. The CT examination was also undertaken when complications were considered during the process of conservative treatment.

Follow-up
During their hospital stay, all patients were clinically evaluated and the drainage amounts fl ushed from the catheters were monitored on a daily basis. Additional imaging was performed with US especially in confi ned abscesses or with CT if necessary. In the presence of improvement in the patients' clinical and imaging fi ndings, the catheters were withdrawn after two weeks at the earliest, considering the maturation period of the tract. Then, according to their general health condition, the patients were either scheduled for elective surgery if appropriate or followed up with clinical evaluation and US. Complications were classifi ed according to Society of Interventional Radiology guidelines [17] and treated accordingly.

Results
Between July 2013 and May 2018, 22 catheter procedures performed in 20 cases, eight female and 12 males, with a perforated gallbladder during conservative treatment were evaluated. The mean age of the patients was 72.2(59-84) years ( Table 1). The drainage catheter was successfully placed    (Table 3).

Discussion
To the best of our knowledge, this is the fi rst study to investigate the safety and effi cacy of percutaneous cholecystostomy for perforated gallbladder after conservative treatment.
In acute cholecystitis, conservative treatment can be performed in high surgical risk patients [3]. If conservative treatment fails, surgery or PC is recommended. Determining this failure is often a subjective assessment of the surgeon or presence of disorders in laboratory assessments, and there are no detailed guidelines on this subject [7,18]. In addition, it is not clear how often a complication with a high morbidity and mortality, such as perforation, is associated with the failure of conservative treatment, and the appropriate approach in such cases. In a prospective study that aimed to predict the failure of conservative treatment involving the use of antibiotics,  Barak et al., [7], reported that this treatment failed, and thus PC was required in 26% of the patients. In another study by Paran et al., [19], PC was performed in 24% of the patients after conservative treatment, and 5.6% of these patients also required emergency surgery and 3.7% died The authors determined PC requirement based on no clinical improvement within 48 hours and symptoms lasting for more than fi ve days.
In both studies described above, the reasons for switching to the PC treatment from conservative therapy were reported to be the absence of improvement in clinical and laboratory fi ndings, but there was no mention of the frequency of perforation as an accompanying complication. In the current study, PC was investigated specifi cally in cases of gallbladder perforation as one of the causes of conservative treatment failure. No patients required emergency surgical intervention, and the 30-day mortality rate was calculated as 5%.
In a study conducted in 2002 to compare PC with conservative treatment in randomized high-risk patient groups, Hatzidakis et al., [8], reported that 11% of the patients in the PC group required emergency surgery. In the PC group, the 30-day mortality was 17.5%, with the deaths being caused by persistent sepsis in 9.5% and an underlying disease in 8%. In the conservative treatment group, the mortality rate was 13%, all due to underlying sepsis. As a result, the authors recommended PC if patients did not respond to treatment within three days. In the present study, the patients were given conservative treatment for an average of 3.65f(2-8) days before perforation was detected and PC was performed.
In a 2007 publication, Huang et al., [6]. compared surgery and PC in high-risk patients with a perforated gallbladder at the time of presentation and found statistically signifi cantly better survival rates and fewer complications in patients who underwent PC, but the duration of hospitalization was longer in this group of patients, albeit not statistically signifi cant [6]. Thus, the authors concluded that PC could be considered as the fi rst treatment option in gallbladder perforation.
Similarly, in a 2017 study comparing surgery and PC [16], no procedure-related mortality was observed in patients that underwent PC, but the 30-day mortality due to comorbidities was 30%. However, mortality in this group was due to medical reasons, rather than septicemia. In the surgical group, the  Acute cholecystitis is mainly an infl ammatory process, and is often uncomplicated, especially in cases of mild course, even without the addition of antibiotics to conservative treatment [24]. However, in patients with moderate or severe acute cholecystitis according to ACSG classifi cation [20], use of antibiotics is recommended [1,25]. In biliary infections, Escherichia coli and Klebsiella pneumoniae are the most common microorganisms growing in culture [26]. In the current study, all patients received conservative treatment involving the use of broad-spectrum antibiotics including agents against these bacteria, and the antibiotic agents were altered in the majority of patients according to the post-PC culture and antibiogram analyses.
US is recommended as the fi rst imaging modality in the diagnosis of acute cholecystitis [2]. In cases of perforation, the rate of US revealing wall defects is reported to reach 70% [27], compared to more than 80% for CT [28]. In addition, the CT scan can better detect free fl uid, pericholecystic fl uid, and abscess [15]. Therefore, in case of complications related to cholecystitis, a CT scan is recommended for differentiation [29]. In the present study, US was used as the fi rst imaging method, and the procedure was performed accompanied by US; however, when there was any suspicion of complications, especially in the presence of abscess or perihepatic fl uid, CT was also undertaken.
The limitations of the study include the small sample size, retrospective nature, and the PC results not being compared to surgery. In addition, since the total number of patients that received conservative treatment was not known, the rate of failure of conservative treatment and the rate of perforation among cases of failure were also not evaluated.

Conclusion
Especially in high surgical risk patients, PC presents as an effective and reliable treatment of gallbladder perforation, one of the causes of failure of conservative acute cholecystitis treatment, leading to signifi cant mortality and morbidity.