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Routine surveillance cholangiography after percutaneous cholecystostomy delays drain removal and cholecystectomy

Loftus, Tyler J. MD; Brakenridge, Scott C. MD, MSCS; Moore, Frederick A. MD; Dessaigne, Camille G. MD; Sarosi, George A. Jr. MD; Zingarelli, William J. MD; Jordan, Janeen R. MD; Croft, Chasen A. MD; Smith, R. Stephen MD; Efron, Philip A. MD; Mohr, Alicia M. MD

Journal of Trauma and Acute Care Surgery: February 2017 - Volume 82 - Issue 2 - p 351–355
doi: 10.1097/TA.0000000000001315
Original Articles
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CME

Introduction Percutaneous cholecystostomy (PC) is often performed for patients with acute cholecystitis who are at high risk for operative morbidity and mortality. However, the necessity for routine cholangiography after PC remains unclear. We hypothesized that routine surveillance cholangiography (RSC) after PC would provide no benefit compared to on-demand cholangiography (ODC) triggered by signs or symptoms of biliary pathology.

Methods We performed a 3-year retrospective cohort analysis of patients managed with PC for acute cholecystitis at two tertiary care hospitals. Patients who had routine surveillance cholangiography (RSC, n = 43) were compared to patients who had on-demand cholangiography (ODC, n = 41) triggered by recurrent biliary disease.

Results RSC and ODC groups were similar by severity of acute cholecystitis, presence of gallstones, systemic inflammatory response syndrome (SIRS) criteria at the time of PC, SIRS criteria 72 hours after PC, and hospital length of stay. Two patients in the ODC group developed clinical indications for cholangiography. All 44 RSC patients had cholangiography, and 67 total cholangiograms were performed in this group. Surveillance cholangiography identified six patients (14%) with cystic duct filling defect and seven patients (16%) with a common bile duct filling defect, all of whom were asymptomatic. Fifteen patients (35%) in the RSC group had 32 ERCP procedures; five patients (12%) in the ODC group had 7 ERCPs (p = 0.021). The ODC group had fewer days to drain removal (35 vs. 61, p < 0.001) and days to cholecystectomy (39 vs. 81, p = 0.005). Rates of recurrent cholecystitis, cholangitis, gallstone pancreatitis, drain removal, and cholecystectomy were similar between groups.

Conclusion RSC after PC for acute cholecystitis identified biliary pathology in asymptomatic patients and propagated further testing, but did not provide clinical benefit. ODC was associated with earlier drain removal, earlier cholecystectomy, and decreased resource utilization.

Level of Evidence Prognostic study, level III; therapeutic study, level IV.

From the Department of Surgery and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, Florida (all authors).

Submitted: June 29, 2016, Revised: September 15, 2016, Accepted: September 27, 2016, Published online: November 23, 2016.

This submission has not been published elsewhere and the authors have nothing to disclose.

This work was supported in part by grants P30 AG028740 (P.A.E., S.C.B.) awarded by the National Institute on Aging and by R01 GM113945-01 (P.A.E.), R01 GM105893-01A1 (A.M.M.), P50 GM111152–01 (S.C.B., F.A.M., P.A.E., A.M.M.) awarded by the National Institute of General Medical Sciences (NIGMS). T.J.L. was supported by a postgraduate training grant (T32 GM-08721) in burns, trauma, and perioperative injury by NIGMS.

Address for reprints: Alicia M. Mohr, MD, FACS, FCCM, Department of Surgery, University of Florida, 1600 SW Archer Road, Box 100108, Gainesville, FL 32610; email: alicia.mohr@surgery.ufl.edu.

© 2017 Lippincott Williams & Wilkins, Inc.