Cholecystostomy Drainage; Current Practices in a Tertiary Hepatobiliary Unit

Cholecystostomy Drainage; Current Practices in a Tertiary Hepatobiliary Unit | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Cholecystostomy Drainage; Current Practices in a Tertiary Hepatobiliary Unit M Al Azzawi, C Cullinane, C Manole, A Coffey, D O’Neill, C O’Sulleabhain, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6208563/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Acute calculous cholecystitis is a common general surgical emergency and accounts for 20% of symptomatic gallstone presentations. According to the Tokyo Guidelines, the severity is stratified into mild, moderate, and severe. Percutaneous Cholecystostomy Drains (PCD) are a temporary intervention in acutely unwell patients with gallbladder disease. This study aims to assess the current utility of PCDs in a tertiary hepatobiliary referral centre. Methods This retrospective review of PCD patients treated in a tertiary hepatobiliary referral centre between January 2018 and December 2023. Clinical, radiological, and perioperative outcomes were measured. Descriptive analysis was performed using the GraphPad Prism program. Results Sixty-eight patients were identified over six years. The mean age was 71.6 years, with a male majority. The inpatient referral group had a higher rate of ASA IV score (43%, n=18) compared to the external referral group (39%, n=7) (p-value = 0.775). The most common diagnosis was severe cholecystitis with septic shock (33.8%), followed by gallbladder perforation (26.4%). Complications occurred in 4.4% of cases, and 61.7% of patients had a follow-up cholecystogram. The mean duration of PCT insertion was 95.78 days in our cohort. Completion cholecystectomy was performed in 87.1% of patients with ASA I-II and 40% with ASA III-IV (p value<0.05). Conclusion Percutaneous Cholecystostomy Drainage is a safe and effective procedure for managing acutely calculous cholecystitis. However, the significant heterogeneity in the literature regarding the management and follow-up guidelines of PCT for patients with severe cholecystitis calls for further research. Future studies should focus on establishing best practice guidelines for PCT follow-up, a crucial area that this study has identified for further exploration. Health sciences/Diseases Health sciences/Diseases/Gastrointestinal diseases Health sciences/Gastroenterology/Gastrointestinal diseases Health sciences/Gastroenterology/Hepatology Health sciences/Gastroenterology/Hepatology/Biliary tract disease Acute cholecystitis Percutaneous cholecystostomy tubes cholecystograms laparoscopic cholecystectomy open cholecystectomy Background Acute calculous cholecystitis is a common general surgical emergency and accounts for 20% of symptomatic gallstone presentations (1). Non-operative management of calculous cholecystitis leads to a significant risk of developing future gallstone-related complications. After an episode of acute cholecystitis, the probability of developing biliary colic, an obstructed biliary system or pancreatitis is 14%,19% and 29% at 6 weeks, 12 weeks and 1 year, respectively (2). Current best practice guidelines recommend laparoscopic cholecystectomy for acute calculous cholecystitis, and many international bodies endorse this (3, 4). The clinical manifestations of acute calculous cholecystitis vary considerably as it’s a heterogeneous condition with varying degrees of severity. First introduced in 2013 and updated in 2018, the Tokyo guidelines (TG) sought to establish objective parameters for the diagnosis and severity grading of acute cholecystitis (5). The most recent TG18 severity grading system classifies acute cholecystitis into grades 1 to 3 based on progressive organ dysfunction and worsening laboratory values. This classification system predicts inpatient mortality, length of stay and surgical outcomes according to disease severity (6–8). Furthermore, TG18 provides recommendations on the optimal treatment strategies for different cholecystitis severity grades, with grade 1 and selected grade 2 (within 96 hours) cases suitable for acute laparoscopic cholecystectomy and grade III cases more suited towards more conservative radiological intervention (5). The gold standard for acute cholecystitis is early laparoscopic cholecystectomy; however, for certain patients with multiple comorbidities, advanced age, and/or sepsis, percutaneous cholecystostomy may represent a safe and suitable alternative treatment option (3). Critics of the CHOCOLATE study (Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high-risk patients) suggest that percutaneous drainage should only be employed for delayed presentation, extensive co-morbidities, frailty or severe systemic illness(9). Percutaneous cholecystostomy (PC), usually performed by interventional radiologists, can be placed via percutaneous transhepatic gallbladder drainage, percutaneous transperitoneal gallbladder drainage or percutaneous transhepatic gallbladder aspiration(10). Previous publications have reported significant variation in the clinical indication, duration, removal and follow-up of percutaneous cholecystostomy drainage procedure (11). There are no consensus guidelines or established management algorithms on the optimal management of percutaneous cholecystostomy drains. This study examined the management and outcomes of percutaneous cholecystostomy in a tertiary hepatobiliary unit. Aims & Methodology This is a retrospective review of percutaneous cholecystostomy drain (PCD) insertions conducted between January 2018 and December 2023 at a tertiary hepatobiliary referral centre. The study evaluated current real-world clinical practices regarding managing percutaneous cholecystostomy tubes. The data collection process was meticulous, following the approval of the Research Ethics Committee Board at Mercy University Hospital and University College Cork. All methods were carried out in accordance with relevant guidelines and regulations. This was a retrospective study; informed consent was not required per the Clinical Research Ethics Committee of the Cork Teaching Hospitals and national regulations (Application reference ECM 3 and ECM 4). Participants were anonymised during data processing according to GDPR guidelines. Procedures labelled as “cholecystostomy tubes” and “cholecystograms” were screened and recorded in an Excel sheet by the radiology department at Mercy University Hospital using NIMIS software. Basic demographic data were extracted through patients' unique medical record numbers along with their respective scans. Our analysis's final number of cases was 68 patients, ensuring a comprehensive representation of the patient population. Clinical, radiological, and follow-up outcomes were extracted and verified between January and April 2024, providing the accuracy and reliability of the data. Data Collection: For the study, an Excel database encompassed patients' demographics and radiological, clinical and perioperative outcomes. Patients were pseudonymised under a unique code, and the password-protected database was saved on a hospital desktop within the surgical department in accordance with the General Data Protection Regulation (GDPR). Patients’ demographics and clinical and pathological outcomes were retrieved through the online iCare system. Follow-up data was collected from medical charts and follow-up letters on T-PRO software. Basic demographics included age, gender, American Society of Anaesthesiology (ASA) score, diagnosis and source of referral (inpatient versus outpatient referral). ASA grade was stratified according to the referral source for our patient cohort. Radiology outcomes were gathered by radiology trainees (CM and AC) through a retrospective assessment of radiological scans at the time of admission. Measured outcomes included the date of PCD insertion, the insertion method, complications during the procedure, radiological findings (gallbladder perforation, Common Bile Duct (CBD) stones, or regional abscess), and the timing of follow-up cholecystogram. Clinical outcomes were collected by the primary investigator (MA). Clinical outcomes comprised the duration of index admission, the duration PCD remained in situ, the rate of completion cholecystectomy, recurrence, and readmission rates. Statistical Analysis: Results for basic demographics, clinical outcomes, and radiological findings were analysed using descriptive statistical methods. Continuous variables were presented as the mean with standard deviation or median with interquartile range. Categorical variables were analysed using the Chi-Squared test. GraphPad Prism was used for data analysis. Results Basic Demographics: Between January 2018 and December 2023, sixty-eight patients underwent percutaneous cholecystostomy drain placement at a Tertiary University Hospital. The mean age was 71.59 years, and the majority of patients were male (66.18%). The most common ASA score was III (51.4%). Forty-seven cases were referred internally within the hospital, while twenty-one were external referrals from regional hospitals. The inpatient referral group had a higher rate of ASA IV score (42.86%) compared to the external referral group (38.89%) (p-value = 0.7755). The most common diagnosis was severe cholecystitis with septic shock (33.8%), followed by gallbladder perforation (26.4%). Seven cases underwent a PCD as a palliative procedure for an obstructing cancerous mass. There were four cases of pancreatic cancer resulting in external CBD obstruction, two cases of cholangiocarcinoma, and the last case had an external compression of CBD by a duodenal adenocarcinoma. One case experienced a failed ERCP, resulting in an iatrogenic CBD perforation. Two cases proceeded to laparotomy: one for a palliative hepaticojejunostomy and the other for abscess drainage. The basic demographics of our patient cohort can be seen in Table 1 . Table 1 Basic Demographics Of Patients Underwent Percutaneous Cholecystostomy Drain Insertion In The Mercy University Hospital Between January 2018 and December 2022. Basic Demographics : Patients With Percutaneous Cholecystostomy Drains (n = 68) Age 71.59 years (mean) Sex Male: 45 (66.18%) Female: 23 (33.82%) ASA Grade ASA II: 8 (11.8%) ASA III: 35 (51.4%) ASA IV: 25 (36.7%) Diagnosis Acute Cholecystitis: 23 (33.8%) Gall Bladder Empyema: 4 (5.8%) Gall Bladder Perforation: 18 (26.4%) Gall Bladder Perforation With Liver Abscess: 9 (13.2%) CBD Obstruction Secondary to Malignancy: 7 Cholangiocarcinoma: 2 (2.9%) Pancreatic Cancer with Biliary Obstruction: 4 (5.8%) Duodenal Adenocarcinoma: Ascending Cholangitis Secondary to Gallstones: 6 (8.8%) Other: 3 (4.4%) Radiological Outcomes: The most frequently used cholecystostomy catheter size was 8-8.5 French. The predominant mode of insertion was transhepatic (73.5%), followed by transperitoneal insertion (17.6%). Three complications were reported out of the sixty-eight cases; one case involved a hepatic artery injury necessitating interventional radiology embolisation and subsequent laparotomy. The other two cases experienced tube-associated complications: a bile leak with a subcapsular abscess and a liver abscess. Four cholecystostomy drains required replacement and repositioning due to dislodgement or broken catheters. Fifteen patients had CBD stones and nine of them underwent Endoscopic Retrograde Cholangiopancreatography (ERCP) following percutaneous cholecystostomy insertion because of obstructing choledocholithiasis and concomitant ascending cholangitis. Cholecystograms were performed in 42 out of 68 cases (61.7%), with the majority conducted within six weeks of PCD insertion (78.5%). The mean duration of PCT placement in our cohort was 95.78 days. The main radiological outcomes are illustrated in Table 2 . Table 2 Radiological Outcomes of Patients Who Underwent Percutaneous Cholecystostomy Drain Insertion Radiological Outcomes: Patients With Percutaneous Cholecystostomy Drains (n = 68) Mode of Insertion Transhepatic: 50/68 (73.5%) Transperitoneal: 12/68 (17.6%) Unknown: 6/68 (8.8%) Radiological Findings CBD stones: 15/68 Gallbladder Perforation: 27/68 Hepatic Abscess: 7/68 Post Procedure Outcomes Re-intervention: 11/68 Complications: 3/68 Other procedures (I.E. ERCP, externalization of biliary drain): 6/68 Future PTC: 6/68 Post Insertion Cholecystogram Post PCD Cholecystograms : 42/68 (61.7%) Timing of Cholecystogram : 12 weeks: 6/42 Duration of insertion : 95.78 days (mean) Clinical Outcomes: Our patient cohort’s mean length of stay was 15.75 days (SD 11.23, 95% CI 12.77–18.74). Twenty-seven patients proceeded to have a completion cholecystectomy, while seven patients passed away as inpatients due to septic shock and multiorgan failure. The mean duration between PCD insertion and cholecystectomy was 164.8 days (SD 167.3, 95% CI 99.92–229.7). The rate of completion cholecystectomy was 87.1% in patients with ASA I-II and 40% in patients with ASA III-IV (p-value < 0.05). Additionally, 14.29% of ASA I-II and 60% of ASA III-IV patients did not have a completion cholecystectomy (p-value < 0.05). Of the 27 cholecystectomies performed, nineteen were laparoscopic, six were open, and one involved a conversion from laparoscopic to open. Five of the open cholecystectomy cases were performed for curative purposes, while one was a palliative cancer procedure. The readmission rate was 25%, with the most common cause of admission being a recurrence of acute cholecystitis (n = 15), followed by choledocholithiasis. Inpatient mortality was 10.29% (n = 7/68), and the 30-day mortality rate was 19.11% (n = 13/68). A summary of the clinical outcomes can be found in Table 3 . Table 3 Clinical Outcomes Of Patients Who Underwent Percutaneous Cholecystostomy Drain Insertion Clinical Outcomes: Patients With Percutaneous Cholecystostomy Drain (n = 68) Recurrence of cholecystitis and Readmission 15/68 (22%) Duration of Index Admission 15.75 days Future Cholecystectomy 27/68 Cholecystectomy Approach Open Cholecystectomy 6/27 Laparoscopic Cholecystectomy : 19/27 Laparoscopic converted to open : 1/27 Mortality Within 30 Days 19.11% (13/68) Discussion and Literature Review Acute cholecystitis, a prevalent emergency general surgery condition, is classified as mild, moderate or severe based on clinical and biochemical parameters relating to the presence of sepsis and multi-organ failure (12). Contemporary data supports early laparoscopic cholecystectomy in surgically fit patients presenting with acute calculous cholecystitis for definitive treatment (4). Restricted access to the emergency operating theatre, patients' comorbidities, and physiological extremes at the time of presentation are the main obstacles to performing an emergency laparoscopic cholecystectomy. Therefore, percutaneous cholecystostomy tubes have emerged as an acceptable alternative for acutely unwell patients. Indications and Safety of Percutaneous Cholecystostomy Drains: The Tokyo guidelines recommend using percutaneous cholecystostomy drains as an alternative to emergency cholecystectomy for acutely unwell patients with a high ASA score and The Charlson Comorbidity Index (CCI) (4, 13). The World Society of Emergency Surgery guidelines similarly endorse PCD as an alternative for patients with severe comorbidities (3). PCD is a definitive treatment for comorbid patients with severe acute cholecystitis (grades III and IV) (14). Cholecystostomy drains also serve as a bridge in managing acute cholecystitis in acutely unwell patients until a safe interval cholecystectomy can be performed. Our study is a retrospective review of all PCD cases conducted over six years in a tertiary hepatobiliary referral centre. In accordance with international guidelines, the ASA scores were III or higher in nearly 90% of our patient cohort who underwent percutaneous drainage. All cases were diagnosed with grade III severe cholecystitis, with the most common indication being severe acute cholecystitis with septic shock, followed by gallbladder perforation and concomitant malignancy. Percutaneous cholecystostomy is a low-risk procedure that can bridge cholecystectomy once patients are clinically stable and inflammation has settled (15). Procedural complication rates as high as 9% have been reported, with the most frequently noted complications including dislodgement, bile leak, post-insertion haemorrhage, worsening of sepsis, and organ perforation (16, 17). Similar to the published literature, the complication rate in our patient cohort is low at 4.41% (n = 3), with the most common complications being tube dislodgement and bile leak. This demonstrates that PCD has an acceptable safety profile, which is advantageous for a particularly comorbid and physiologically vulnerable cohort of patients. Post-Insertion Management of Percutaneous Cholecystostomy Drains: There is a lack of consensus guidelines on the follow-up imaging and optimum timing of removal of PCD. Most centres follow anecdotal evidence and local policies to determine the timing of PCD removal and the need for follow-up imaging. The literature suggests keeping the PCD in situ for 4–6 weeks before removal to allow tract maturation and avoid early bile leak (18). Noh et al. suggested leaving the PCD for at least two weeks for transhepatic and three weeks for transperitoneal insertion to allow for tract maturation (19). Pre-removal cholecystogram does not impact the overall rate of recurrence. However, a pre-removal clamping test from forty-eight hours up to two weeks effectively prevented the recurrence of cholecystitis (10, 20, 21). Our institution's mean duration of PCD placement was 95.9 days among our patient cohort. Post-drain insertion cholecystograms were performed in 61.7% of cases, with the majority occurring within the first six weeks post-insertion (n = 33). PCDs were removed in the outpatient department or by Interventional Radiology following cholecystograms. Cholecystograms were carried out to evaluate the cystic and common bile duct patency. The clamping test was not routinely conducted in our cohort of patients. Completion Cholecystectomy Post Percutaneous Cholecystostomy Drains: While PCD can be considered a definitive procedure in specific clinical scenarios, interval laparoscopic cholecystectomy can be performed safely post-insertion. Studies have shown that perioperative complications can be as low as 5.3–8.6%, with a mortality rate of 0.96%(10, 22). Despite the low rate of perioperative complications, the Tokyo Guidelines 2018 still recommends expectant management for patients with ASA > = 3 and CCI score of > = 4 (4). Interval laparoscopic cholecystectomy post PCD insertion should ideally be performed within four to eight weeks to avoid PCD-related complications and recurrence of biliary disease (23). Woodward et al. demonstrated a higher rate of complications when interval cholecystectomy is performed within four weeks of PCD insertion (23). In our patient cohort, the mean interval between drain insertion and completion of cholecystectomy was 164.8 days (SD 167.3, 95% CI 99.92–229.7). This can be attributed to the severity of illness in the majority of our patients, their poor baseline functional status, and restricted access to the operating theatre. The rate of post-PCD completion cholecystectomy varies in the literature. An American nationwide survey assessed the rate of readmissions post-PCD insertion (24). The survey showed that 62.2% of patients with PCD did not proceed to a completion cholecystectomy (24). Moreover, there was a 20% readmission rate for biliary disease in the PCD cohort (24). De Mestral et al. reported a completion cholecystectomy rate of 40% at 1-year post-drain insertion and a recurrence rate of 49% in patients who did not undergo definitive treatment (25). Other studies indicated a cholecystectomy rate as low as 14%, suggesting that PCD can be regarded as a safe, definitive procedure for managing biliary disease (26, 27). Our completion cholecystectomy rate was 39.7%, and the readmission rate was 25%. In some cases, the PCD was maintained in situ until the day of surgery, while in others, it was performed as a palliative procedure for patients with locally advanced cancer causing external obstruction of the CBD and ascending cholangitis (7/68). Limitations: This single-centre study involves a retrospective review of patients treated with percutaneous cholecystostomy at a tertiary hepatobiliary centre. Our patient cohort consists of 68 individuals over six years, a low number compared to previously published literature. The study was conducted in a hepatobiliary centre where laparoscopic cholecystectomy for acutely inflamed gallbladders can be a viable option due to the availability of expertise and facilitated access to emergency theatres. The findings highlight the heterogeneity and ambiguity in managing and following percutaneous cholecystostomy tubes. Currently, there is a lack of standardised guidelines for managing and following PCDs. Further research should focus on generating these guidelines. Conclusion PCDs are safe and effective in managing severe cholecystitis in patients with comorbidities. They serve as a safe and effective bridge to cholecystectomy. Future studies should focus on establishing guidelines for managing and following up on PCDs. Declarations Date availability: Data underlying the results presented in this paper may be obtained from the corresponding author upon reasonable request." Ethics Statement: Ethics approval was obtained from the Research Ethics Committee Board at Mercy University Hospital and University College Cork. Human Ethics and Consent to Participate declarations was not necessary as per the ethics committee. Conflict and Project Funding: No conflicts of interest to declare, no funding obtained. References Shaffer EA. Epidemiology and risk factors for gallstone disease: has the paradigm changed in the 21st century? Curr Gastroenterol Rep. 2005;7(2):132-40. de Mestral C, Rotstein OD, Laupacis A, Hoch JS, Zagorski B, Nathens AB. A population-based analysis of the clinical course of 10,304 patients with acute cholecystitis, discharged without cholecystectomy. J Trauma Acute Care Surg. 2013;74(1):26-30; discussion -1. Ansaloni L, Pisano M, Coccolini F, Peitzmann AB, Fingerhut A, Catena F, et al. 2016 WSES guidelines on acute calculous cholecystitis. World J Emerg Surg. 2016;11:25. Okamoto K, Suzuki K, Takada T, Strasberg SM, Asbun HJ, Endo I, et al. 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HPB (Oxford). 2009;11(3):183-93. Woodward SG, Rios-Diaz AJ, Zheng R, McPartland C, Tholey R, Tatarian T, et al. Finding the Most Favorable Timing for Cholecystectomy after Percutaneous Cholecystostomy Tube Placement: An Analysis of Institutional and National Data. J Am Coll Surg. 2021;232(1):55-64. Pavurala RB, Li D, Porter K, Mansfield SA, Conwell DL, Krishna SG. Percutaneous cholecystostomy-tube for high-risk patients with acute cholecystitis: current practice and implications for future research. Surg Endosc. 2019;33(10):3396-403. de Mestral C, Gomez D, Haas B, Zagorski B, Rotstein OD, Nathens AB. Cholecystostomy: a bridge to hospital discharge but not delayed cholecystectomy. J Trauma Acute Care Surg. 2013;74(1):175-9; discussion 9-80. Leveau P, Andersson E, Carlgren I, Willner J, Andersson R. Percutaneous cholecystostomy: a bridge to surgery or definite management of acute cholecystitis in high-risk patients? Scand J Gastroenterol. 2008;43(5):593-6. Popowicz A, Lundell L, Gerber P, Gustafsson U, Pieniowski E, Sinabulya H, et al. Cholecystostomy as Bridge to Surgery and as Definitive Treatment or Acute Cholecystectomy in Patients with Acute Cholecystitis. Gastroenterol Res Pract. 2016;2016:3672416. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6208563","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":482354038,"identity":"729aa091-5c1e-445e-a8a9-51285a659242","order_by":0,"name":"M Al Azzawi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIiWNgGAWjYFACHjDJ2MAO5fKDyASitDBDuZINpGphMDhAwFm67b0HP93MsZHtb2Z+/PFHzWEZ49uHH394wGAnp9uAXYvZmXPJ0rnb0oxnHGYzMJA4dpjH7FyamUQCQ7KxGQ7rzG7kGAC1HE5sOMxgkGDAdpvH7AwPG9AvBxK34dZi/Dt32//E+YfZPxxI+Hebx7iHh/kDAS1mQFsOJG44zGPYcLDtNo8BDw+DBF4tZ86YWeduSzbeeJinmLGx7z+PxBk2oF8M8PjleI/x7dxtdrLzjrdv/vjjW5o9fw8o6Crs5HBpwQUMSFM+CkbBKBgFowAVAABnHF+bFUcufgAAAABJRU5ErkJggg==","orcid":"","institution":"Department of General Surgery, Mercy University Hospital","correspondingAuthor":true,"prefix":"","firstName":"M","middleName":"Al","lastName":"Azzawi","suffix":""},{"id":482354039,"identity":"dbdca4a4-4b0f-48cc-8351-830f4129641d","order_by":1,"name":"C Cullinane","email":"","orcid":"","institution":"Department of General Surgery, Mercy University Hospital","correspondingAuthor":false,"prefix":"","firstName":"C","middleName":"","lastName":"Cullinane","suffix":""},{"id":482354040,"identity":"58c8e13b-02e2-4eb3-b72f-5ede1d22a181","order_by":2,"name":"C Manole","email":"","orcid":"","institution":"Department of Radiology, Mercy University Hospital","correspondingAuthor":false,"prefix":"","firstName":"C","middleName":"","lastName":"Manole","suffix":""},{"id":482354041,"identity":"da1bd4ca-90f8-4251-aabe-c185d3055623","order_by":3,"name":"A Coffey","email":"","orcid":"","institution":"Department of Radiology, Mercy University Hospital","correspondingAuthor":false,"prefix":"","firstName":"A","middleName":"","lastName":"Coffey","suffix":""},{"id":482354042,"identity":"cfc4ced1-58b3-4ea3-9cfd-7772605eb830","order_by":4,"name":"D O’Neill","email":"","orcid":"","institution":"Department of Radiology, Mercy University Hospital","correspondingAuthor":false,"prefix":"","firstName":"D","middleName":"","lastName":"O’Neill","suffix":""},{"id":482354043,"identity":"b6f1d1c2-8542-420a-be1f-e1452227c601","order_by":5,"name":"C O’Sulleabhain","email":"","orcid":"","institution":"Department of General Surgery, Mercy University Hospital","correspondingAuthor":false,"prefix":"","firstName":"C","middleName":"","lastName":"O’Sulleabhain","suffix":""},{"id":482354044,"identity":"79f5c9d2-22a2-4ed2-84fc-413e94822c9b","order_by":6,"name":"A O’Sullivan","email":"","orcid":"","institution":"Department of General Surgery, Mercy University Hospital","correspondingAuthor":false,"prefix":"","firstName":"A","middleName":"","lastName":"O’Sullivan","suffix":""},{"id":482354046,"identity":"2b084d12-d31b-4031-9085-d97875de4342","order_by":7,"name":"T Murphy","email":"","orcid":"","institution":"Department of General Surgery, Mercy University Hospital","correspondingAuthor":false,"prefix":"","firstName":"T","middleName":"","lastName":"Murphy","suffix":""}],"badges":[],"createdAt":"2025-03-12 04:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6208563/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6208563/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95655343,"identity":"c6f50ac2-0e25-46c5-9f1f-a4a89e1f10d2","added_by":"auto","created_at":"2025-11-11 16:15:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":783667,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6208563/v1/5245f335-933e-408f-adff-6bc75df02052.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cholecystostomy Drainage; Current Practices in a Tertiary Hepatobiliary Unit","fulltext":[{"header":"Background","content":"\u003cp\u003eAcute calculous cholecystitis is a common general surgical emergency and accounts for 20% of symptomatic gallstone presentations (1). Non-operative management of calculous cholecystitis leads to a significant risk of developing future gallstone-related complications. After an episode of acute cholecystitis, the probability of developing biliary colic, an obstructed biliary system or pancreatitis is 14%,19% and 29% at 6 weeks, 12 weeks and 1 year, respectively (2). Current best practice guidelines recommend laparoscopic cholecystectomy for acute calculous cholecystitis, and many international bodies endorse this (3, 4).\u003c/p\u003e\u003cp\u003eThe clinical manifestations of acute calculous cholecystitis vary considerably as it\u0026rsquo;s a heterogeneous condition with varying degrees of severity. First introduced in 2013 and updated in 2018, the Tokyo guidelines (TG) sought to establish objective parameters for the diagnosis and severity grading of acute cholecystitis (5). The most recent TG18 severity grading system classifies acute cholecystitis into grades 1 to 3 based on progressive organ dysfunction and worsening laboratory values. This classification system predicts inpatient mortality, length of stay and surgical outcomes according to disease severity (6\u0026ndash;8). Furthermore, TG18 provides recommendations on the optimal treatment strategies for different cholecystitis severity grades, with grade 1 and selected grade 2 (within 96 hours) cases suitable for acute laparoscopic cholecystectomy and grade III cases more suited towards more conservative radiological intervention (5). The gold standard for acute cholecystitis is early laparoscopic cholecystectomy; however, for certain patients with multiple comorbidities, advanced age, and/or sepsis, percutaneous cholecystostomy may represent a safe and suitable alternative treatment option (3).\u003c/p\u003e\u003cp\u003eCritics of the CHOCOLATE study (Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high-risk patients) suggest that percutaneous drainage should only be employed for delayed presentation, extensive co-morbidities, frailty or severe systemic illness(9). Percutaneous cholecystostomy (PC), usually performed by interventional radiologists, can be placed via percutaneous transhepatic gallbladder drainage, percutaneous transperitoneal gallbladder drainage or percutaneous transhepatic gallbladder aspiration(10). Previous publications have reported significant variation in the clinical indication, duration, removal and follow-up of percutaneous cholecystostomy drainage procedure (11). There are no consensus guidelines or established management algorithms on the optimal management of percutaneous cholecystostomy drains. This study examined the management and outcomes of percutaneous cholecystostomy in a tertiary hepatobiliary unit.\u003c/p\u003e"},{"header":"Aims \u0026 Methodology","content":"\u003cp\u003eThis is a retrospective review of percutaneous cholecystostomy drain (PCD) insertions conducted between January 2018 and December 2023 at a tertiary hepatobiliary referral centre. The study evaluated current real-world clinical practices regarding managing percutaneous cholecystostomy tubes. The data collection process was meticulous, following the approval of the Research Ethics Committee Board at Mercy University Hospital and University College Cork. All methods were carried out in accordance with relevant guidelines and regulations. This was a retrospective study; informed consent was not required per the Clinical Research Ethics Committee of the Cork Teaching Hospitals and national regulations (Application reference ECM 3 and ECM 4). Participants were anonymised during data processing according to GDPR guidelines. Procedures labelled as \u0026ldquo;cholecystostomy tubes\u0026rdquo; and \u0026ldquo;cholecystograms\u0026rdquo; were screened and recorded in an Excel sheet by the radiology department at Mercy University Hospital using \u003cem\u003eNIMIS\u003c/em\u003e software. Basic demographic data were extracted through patients' unique medical record numbers along with their respective scans. Our analysis's final number of cases was 68 patients, ensuring a comprehensive representation of the patient population. Clinical, radiological, and follow-up outcomes were extracted and verified between January and April 2024, providing the accuracy and reliability of the data.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eData Collection:\u003c/h2\u003e\u003cp\u003eFor the study, an Excel database encompassed patients' demographics and radiological, clinical and perioperative outcomes. Patients were pseudonymised under a unique code, and the password-protected database was saved on a hospital desktop within the surgical department in accordance with the General Data Protection Regulation (GDPR). Patients\u0026rsquo; demographics and clinical and pathological outcomes were retrieved through the online \u003cem\u003eiCare\u003c/em\u003e system. Follow-up data was collected from medical charts and follow-up letters on \u003cem\u003eT-PRO\u003c/em\u003e software. Basic demographics included age, gender, American Society of Anaesthesiology (ASA) score, diagnosis and source of referral (inpatient versus outpatient referral). ASA grade was stratified according to the referral source for our patient cohort.\u003c/p\u003e\u003cp\u003eRadiology outcomes were gathered by radiology trainees (CM and AC) through a retrospective assessment of radiological scans at the time of admission. Measured outcomes included the date of PCD insertion, the insertion method, complications during the procedure, radiological findings (gallbladder perforation, Common Bile Duct (CBD) stones, or regional abscess), and the timing of follow-up cholecystogram. Clinical outcomes were collected by the primary investigator (MA). Clinical outcomes comprised the duration of index admission, the duration PCD remained in situ, the rate of completion cholecystectomy, recurrence, and readmission rates.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis:\u003c/h2\u003e\u003cp\u003eResults for basic demographics, clinical outcomes, and radiological findings were analysed using descriptive statistical methods. Continuous variables were presented as the mean with standard deviation or median with interquartile range. Categorical variables were analysed using the Chi-Squared test. \u003cem\u003eGraphPad Prism\u003c/em\u003e was used for data analysis.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eBasic Demographics:\u003c/h2\u003e\u003cp\u003eBetween January 2018 and December 2023, sixty-eight patients underwent percutaneous cholecystostomy drain placement at a Tertiary University Hospital. The mean age was 71.59 years, and the majority of patients were male (66.18%). The most common ASA score was III (51.4%). Forty-seven cases were referred internally within the hospital, while twenty-one were external referrals from regional hospitals. The inpatient referral group had a higher rate of ASA IV score (42.86%) compared to the external referral group (38.89%) (p-value\u0026thinsp;=\u0026thinsp;0.7755).\u003c/p\u003e\u003cp\u003eThe most common diagnosis was severe cholecystitis with septic shock (33.8%), followed by gallbladder perforation (26.4%). Seven cases underwent a PCD as a palliative procedure for an obstructing cancerous mass. There were four cases of pancreatic cancer resulting in external CBD obstruction, two cases of cholangiocarcinoma, and the last case had an external compression of CBD by a duodenal adenocarcinoma. One case experienced a failed ERCP, resulting in an iatrogenic CBD perforation. Two cases proceeded to laparotomy: one for a palliative hepaticojejunostomy and the other for abscess drainage. The basic demographics of our patient cohort can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBasic Demographics Of Patients Underwent Percutaneous Cholecystostomy Drain Insertion In The Mercy University Hospital Between January 2018 and December 2022.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eBasic Demographics : Patients With Percutaneous Cholecystostomy Drains (n\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71.59 years (mean)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale: 45 (66.18%)\u003c/p\u003e\u003cp\u003eFemale: 23 (33.82%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eASA Grade\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eASA II: 8 (11.8%)\u003c/p\u003e\u003cp\u003eASA III: 35 (51.4%)\u003c/p\u003e\u003cp\u003eASA IV: 25 (36.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDiagnosis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAcute Cholecystitis: 23 (33.8%)\u003c/p\u003e\u003cp\u003eGall Bladder Empyema: 4 (5.8%)\u003c/p\u003e\u003cp\u003eGall Bladder Perforation: 18 (26.4%)\u003c/p\u003e\u003cp\u003eGall Bladder Perforation With Liver Abscess: 9 (13.2%)\u003c/p\u003e\u003cp\u003eCBD Obstruction Secondary to Malignancy: 7\u003c/p\u003e\u003cp\u003eCholangiocarcinoma: 2 (2.9%)\u003c/p\u003e\u003cp\u003ePancreatic Cancer with Biliary Obstruction: 4 (5.8%)\u003c/p\u003e\u003cp\u003eDuodenal Adenocarcinoma:\u003c/p\u003e\u003cp\u003eAscending Cholangitis Secondary to Gallstones: 6 (8.8%)\u003c/p\u003e\u003cp\u003eOther: 3 (4.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eRadiological Outcomes:\u003c/h3\u003e\n\u003cp\u003eThe most frequently used cholecystostomy catheter size was 8-8.5 French. The predominant mode of insertion was transhepatic (73.5%), followed by transperitoneal insertion (17.6%). Three complications were reported out of the sixty-eight cases; one case involved a hepatic artery injury necessitating interventional radiology embolisation and subsequent laparotomy. The other two cases experienced tube-associated complications: a bile leak with a subcapsular abscess and a liver abscess. Four cholecystostomy drains required replacement and repositioning due to dislodgement or broken catheters. Fifteen patients had CBD stones and nine of them underwent Endoscopic Retrograde Cholangiopancreatography (ERCP) following percutaneous cholecystostomy insertion because of obstructing choledocholithiasis and concomitant ascending cholangitis. Cholecystograms were performed in 42 out of 68 cases (61.7%), with the majority conducted within six weeks of PCD insertion (78.5%). The mean duration of PCT placement in our cohort was 95.78 days. The main radiological outcomes are illustrated in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRadiological Outcomes of Patients Who Underwent Percutaneous Cholecystostomy Drain Insertion\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eRadiological Outcomes: Patients With Percutaneous Cholecystostomy Drains (n\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMode of Insertion\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTranshepatic: 50/68 (73.5%)\u003c/p\u003e\u003cp\u003eTransperitoneal: 12/68 (17.6%)\u003c/p\u003e\u003cp\u003eUnknown: 6/68 (8.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRadiological Findings\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCBD stones: 15/68\u003c/p\u003e\u003cp\u003eGallbladder Perforation: 27/68\u003c/p\u003e\u003cp\u003eHepatic Abscess: 7/68\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePost Procedure Outcomes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRe-intervention: 11/68\u003c/p\u003e\u003cp\u003eComplications: 3/68\u003c/p\u003e\u003cp\u003eOther procedures (I.E. ERCP, externalization of biliary drain): 6/68\u003c/p\u003e\u003cp\u003eFuture PTC: 6/68\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePost Insertion Cholecystogram\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ePost PCD Cholecystograms\u003c/b\u003e: 42/68 (61.7%)\u003c/p\u003e\u003cp\u003e\u003cb\u003eTiming of Cholecystogram\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u0026lt;\u0026thinsp;6 weeks: 33/42\u003c/p\u003e\u003cp\u003e6\u0026ndash;12 weeks: 3/42\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;12 weeks: 6/42\u003c/p\u003e\u003cp\u003e\u003cb\u003eDuration of insertion\u003c/b\u003e: 95.78 days (mean)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eClinical Outcomes:\u003c/h2\u003e\u003cp\u003eOur patient cohort\u0026rsquo;s mean length of stay was 15.75 days (SD 11.23, 95% CI 12.77\u0026ndash;18.74). Twenty-seven patients proceeded to have a completion cholecystectomy, while seven patients passed away as inpatients due to septic shock and multiorgan failure. The mean duration between PCD insertion and cholecystectomy was 164.8 days (SD 167.3, 95% CI 99.92\u0026ndash;229.7). The rate of completion cholecystectomy was 87.1% in patients with ASA I-II and 40% in patients with ASA III-IV (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, 14.29% of ASA I-II and 60% of ASA III-IV patients did not have a completion cholecystectomy (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Of the 27 cholecystectomies performed, nineteen were laparoscopic, six were open, and one involved a conversion from laparoscopic to open. Five of the open cholecystectomy cases were performed for curative purposes, while one was a palliative cancer procedure.\u003c/p\u003e\u003cp\u003eThe readmission rate was 25%, with the most common cause of admission being a recurrence of acute cholecystitis (n\u0026thinsp;=\u0026thinsp;15), followed by choledocholithiasis. Inpatient mortality was 10.29% (n\u0026thinsp;=\u0026thinsp;7/68), and the 30-day mortality rate was 19.11% (n\u0026thinsp;=\u0026thinsp;13/68). A summary of the clinical outcomes can be found in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eClinical Outcomes Of Patients Who Underwent Percutaneous Cholecystostomy Drain Insertion\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eClinical Outcomes: Patients With Percutaneous Cholecystostomy Drain (n\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRecurrence of cholecystitis and Readmission\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15/68 (22%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDuration of Index Admission\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15.75 days\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFuture Cholecystectomy\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27/68\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCholecystectomy Approach\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eOpen Cholecystectomy\u003c/b\u003e 6/27\u003c/p\u003e\u003cp\u003e\u003cb\u003eLaparoscopic Cholecystectomy\u003c/b\u003e: 19/27\u003c/p\u003e\u003cp\u003e\u003cb\u003eLaparoscopic converted to open\u003c/b\u003e: 1/27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMortality Within 30 Days\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19.11% (13/68)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion and Literature Review","content":"\u003cp\u003eAcute cholecystitis, a prevalent emergency general surgery condition, is classified as mild, moderate or severe based on clinical and biochemical parameters relating to the presence of sepsis and multi-organ failure (12). Contemporary data supports early laparoscopic cholecystectomy in surgically fit patients presenting with acute calculous cholecystitis for definitive treatment (4). Restricted access to the emergency operating theatre, patients' comorbidities, and physiological extremes at the time of presentation are the main obstacles to performing an emergency laparoscopic cholecystectomy. Therefore, percutaneous cholecystostomy tubes have emerged as an acceptable alternative for acutely unwell patients.\u003c/p\u003e\n\u003ch3\u003eIndications and Safety of Percutaneous Cholecystostomy Drains:\u003c/h3\u003e\n\u003cp\u003e The Tokyo guidelines recommend using percutaneous cholecystostomy drains as an alternative to emergency cholecystectomy for acutely unwell patients with a high ASA score and The Charlson Comorbidity Index (CCI) (4, 13). The World Society of Emergency Surgery guidelines similarly endorse PCD as an alternative for patients with severe comorbidities (3). PCD is a definitive treatment for comorbid patients with severe acute cholecystitis (grades III and IV) (14). Cholecystostomy drains also serve as a bridge in managing acute cholecystitis in acutely unwell patients until a safe interval cholecystectomy can be performed. Our study is a retrospective review of all PCD cases conducted over six years in a tertiary hepatobiliary referral centre. In accordance with international guidelines, the ASA scores were III or higher in nearly 90% of our patient cohort who underwent percutaneous drainage. All cases were diagnosed with grade III severe cholecystitis, with the most common indication being severe acute cholecystitis with septic shock, followed by gallbladder perforation and concomitant malignancy.\u003c/p\u003e\u003cp\u003ePercutaneous cholecystostomy is a low-risk procedure that can bridge cholecystectomy once patients are clinically stable and inflammation has settled (15). Procedural complication rates as high as 9% have been reported, with the most frequently noted complications including dislodgement, bile leak, post-insertion haemorrhage, worsening of sepsis, and organ perforation (16, 17). Similar to the published literature, the complication rate in our patient cohort is low at 4.41% (n\u0026thinsp;=\u0026thinsp;3), with the most common complications being tube dislodgement and bile leak. This demonstrates that PCD has an acceptable safety profile, which is advantageous for a particularly comorbid and physiologically vulnerable cohort of patients.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003ePost-Insertion Management of Percutaneous Cholecystostomy Drains:\u003c/h2\u003e\u003cp\u003e There is a lack of consensus guidelines on the follow-up imaging and optimum timing of removal of PCD. Most centres follow anecdotal evidence and local policies to determine the timing of PCD removal and the need for follow-up imaging. The literature suggests keeping the PCD in situ for 4\u0026ndash;6 weeks before removal to allow tract maturation and avoid early bile leak (18). Noh et al. suggested leaving the PCD for at least two weeks for transhepatic and three weeks for transperitoneal insertion to allow for tract maturation (19). Pre-removal cholecystogram does not impact the overall rate of recurrence. However, a pre-removal clamping test from forty-eight hours up to two weeks effectively prevented the recurrence of cholecystitis (10, 20, 21). Our institution's mean duration of PCD placement was 95.9 days among our patient cohort. Post-drain insertion cholecystograms were performed in 61.7% of cases, with the majority occurring within the first six weeks post-insertion (n\u0026thinsp;=\u0026thinsp;33). PCDs were removed in the outpatient department or by Interventional Radiology following cholecystograms. Cholecystograms were carried out to evaluate the cystic and common bile duct patency. The clamping test was not routinely conducted in our cohort of patients.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eCompletion Cholecystectomy Post Percutaneous Cholecystostomy Drains:\u003c/h2\u003e\u003cp\u003eWhile PCD can be considered a definitive procedure in specific clinical scenarios, interval laparoscopic cholecystectomy can be performed safely post-insertion. Studies have shown that perioperative complications can be as low as 5.3\u0026ndash;8.6%, with a mortality rate of 0.96%(10, 22). Despite the low rate of perioperative complications, the Tokyo Guidelines 2018 still recommends expectant management for patients with ASA\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;3 and CCI score of \u0026gt;\u0026thinsp;=\u0026thinsp;4 (4). Interval laparoscopic cholecystectomy post PCD insertion should ideally be performed within four to eight weeks to avoid PCD-related complications and recurrence of biliary disease (23). Woodward et al. demonstrated a higher rate of complications when interval cholecystectomy is performed within four weeks of PCD insertion (23). In our patient cohort, the mean interval between drain insertion and completion of cholecystectomy was 164.8 days (SD 167.3, 95% CI 99.92\u0026ndash;229.7). This can be attributed to the severity of illness in the majority of our patients, their poor baseline functional status, and restricted access to the operating theatre.\u003c/p\u003e\u003cp\u003eThe rate of post-PCD completion cholecystectomy varies in the literature. An American nationwide survey assessed the rate of readmissions post-PCD insertion (24). The survey showed that 62.2% of patients with PCD did not proceed to a completion cholecystectomy (24). Moreover, there was a 20% readmission rate for biliary disease in the PCD cohort (24). De Mestral et al. reported a completion cholecystectomy rate of 40% at 1-year post-drain insertion and a recurrence rate of 49% in patients who did not undergo definitive treatment (25). Other studies indicated a cholecystectomy rate as low as 14%, suggesting that PCD can be regarded as a safe, definitive procedure for managing biliary disease (26, 27). Our completion cholecystectomy rate was 39.7%, and the readmission rate was 25%. In some cases, the PCD was maintained in situ until the day of surgery, while in others, it was performed as a palliative procedure for patients with locally advanced cancer causing external obstruction of the CBD and ascending cholangitis (7/68).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eLimitations:\u003c/h2\u003e\u003cp\u003eThis single-centre study involves a retrospective review of patients treated with percutaneous cholecystostomy at a tertiary hepatobiliary centre. Our patient cohort consists of 68 individuals over six years, a low number compared to previously published literature. The study was conducted in a hepatobiliary centre where laparoscopic cholecystectomy for acutely inflamed gallbladders can be a viable option due to the availability of expertise and facilitated access to emergency theatres. The findings highlight the heterogeneity and ambiguity in managing and following percutaneous cholecystostomy tubes. Currently, there is a lack of standardised guidelines for managing and following PCDs. Further research should focus on generating these guidelines.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePCDs are safe and effective in managing severe cholecystitis in patients with comorbidities. They serve as a safe and effective bridge to cholecystectomy. Future studies should focus on establishing guidelines for managing and following up on PCDs.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDate availability:\u0026nbsp;\u003c/strong\u003eData underlying the results presented in this paper may be obtained from the corresponding author upon reasonable request.\"\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Statement:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval was obtained from the Research Ethics Committee Board at Mercy University Hospital and University College Cork.\u0026nbsp;Human Ethics and Consent to Participate declarations was not necessary as per the ethics committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict and Project Funding:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo conflicts of interest to declare, no funding obtained.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eShaffer EA. Epidemiology and risk factors for gallstone disease: has the paradigm changed in the 21st century? Curr Gastroenterol Rep. 2005;7(2):132-40.\u003c/li\u003e\n\u003cli\u003ede Mestral C, Rotstein OD, Laupacis A, Hoch JS, Zagorski B, Nathens AB. A population-based analysis of the clinical course of 10,304 patients with acute cholecystitis, discharged without cholecystectomy. J Trauma Acute Care Surg. 2013;74(1):26-30; discussion -1.\u003c/li\u003e\n\u003cli\u003eAnsaloni L, Pisano M, Coccolini F, Peitzmann AB, Fingerhut A, Catena F, et al. 2016 WSES guidelines on acute calculous cholecystitis. World J Emerg Surg. 2016;11:25.\u003c/li\u003e\n\u003cli\u003eOkamoto K, Suzuki K, Takada T, Strasberg SM, Asbun HJ, Endo I, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):55-72.\u003c/li\u003e\n\u003cli\u003eYokoe M, Hata J, Takada T, Strasberg SM, Asbun HJ, Wakabayashi G, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25(1):41-54.\u003c/li\u003e\n\u003cli\u003ePaul Wright G, Stilwell K, Johnson J, Hefty MT, Chung MH. Predicting length of stay and conversion to open cholecystectomy for acute cholecystitis using the 2013 Tokyo Guidelines in a US population. J Hepatobiliary Pancreat Sci. 2015;22(11):795-801.\u003c/li\u003e\n\u003cli\u003eKamalapurkar D, Pang TC, Siriwardhane M, Hollands M, Johnston E, Pleass H, et al. Index cholecystectomy in grade II and III acute calculous cholecystitis is feasible and safe. ANZ J Surg. 2015;85(11):854-9.\u003c/li\u003e\n\u003cli\u003eAmirthalingam V, Low JK, Woon W, Shelat V. Tokyo Guidelines 2013 may be too restrictive and patients with moderate and severe acute cholecystitis can be managed by early cholecystectomy too. Surg Endosc. 2017;31(7):2892-900.\u003c/li\u003e\n\u003cli\u003eLoozen CS, van Santvoort HC, van Duijvendijk P, Besselink MG, Gouma DJ, Nieuwenhuijzen GA, et al. Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial. BMJ. 2018;363:k3965.\u003c/li\u003e\n\u003cli\u003eHung YL, Sung CM, Fu CY, Liao CH, Wang SY, Hsu JT, et al. Management of Patients With Acute Cholecystitis After Percutaneous Cholecystostomy: From the Acute Stage to Definitive Surgical Treatment. Front Surg. 2021;8:616320.\u003c/li\u003e\n\u003cli\u003eElsharif M, Forouzanfar A, Oaikhinan K, Khetan N. Percutaneous cholecystostomy\u0026hellip; why, when, what next? A systematic review of past decade. Ann R Coll Surg Engl. 2018;100(8):1-14.\u003c/li\u003e\n\u003cli\u003eHirota M, Takada T, Kawarada Y, Nimura Y, Miura F, Hirata K, et al. Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg. 2007;14(1):78-82.\u003c/li\u003e\n\u003cli\u003eDoyle DJ, Hendrix JM, Garmon EH. American Society of Anesthesiologists Classification. StatPearls. Treasure Island (FL)2024.\u003c/li\u003e\n\u003cli\u003eBoules M, Haskins IN, Farias-Kovac M, Guerron AD, Schechtman D, Samotowka M, et al. What is the fate of the cholecystostomy tube following percutaneous cholecystostomy? Surg Endosc. 2017;31(4):1707-12.\u003c/li\u003e\n\u003cli\u003eSanjay P, Mittapalli D, Marioud A, White RD, Ram R, Alijani A. Clinical outcomes of a percutaneous cholecystostomy for acute cholecystitis: a multicentre analysis. HPB (Oxford). 2013;15(7):511-6.\u003c/li\u003e\n\u003cli\u003eWise JN, Gervais DA, Akman A, Harisinghani M, Hahn PF, Mueller PR. Percutaneous cholecystostomy catheter removal and incidence of clinically significant bile leaks: a clinical approach to catheter management. AJR Am J Roentgenol. 2005;184(5):1647-51.\u003c/li\u003e\n\u003cli\u003eKarakas HM, Yildirim G, Fersahoglu MM, Findik O. Percutaneous cholecystostomy: An update for the 2020s. North Clin Istanb. 2021;8(5):537-42.\u003c/li\u003e\n\u003cli\u003eFleming CA, Ismail M, Kavanagh RG, Heneghan HM, Prichard RS, Geoghegan J, et al. Clinical and Survival Outcomes Using Percutaneous Cholecystostomy Tube Alone or Subsequent Interval Cholecystectomy to Treat Acute Cholecystitis. J Gastrointest Surg. 2020;24(3):627-32.\u003c/li\u003e\n\u003cli\u003eNoh SY, Gwon DI, Ko GY, Yoon HK, Sung KB. Role of percutaneous cholecystostomy for acute acalculous cholecystitis: clinical outcomes of 271 patients. Eur Radiol. 2018;28(4):1449-55.\u003c/li\u003e\n\u003cli\u003ePark JK, Yang JI, Wi JW, Park JK, Lee KH, Lee KT, et al. Long-term outcome and recurrence factors after percutaneous cholecystostomy as a definitive treatment for acute cholecystitis. J Gastroenterol Hepatol. 2019;34(4):784-90.\u003c/li\u003e\n\u003cli\u003eLoftus TJ, Brakenridge SC, Moore FA, Dessaigne CG, Sarosi GA, Jr., Zingarelli WJ, et al. Routine surveillance cholangiography after percutaneous cholecystostomy delays drain removal and cholecystectomy. J Trauma Acute Care Surg. 2017;82(2):351-5.\u003c/li\u003e\n\u003cli\u003eWinbladh A, Gullstrand P, Svanvik J, Sandstrom P. Systematic review of cholecystostomy as a treatment option in acute cholecystitis. HPB (Oxford). 2009;11(3):183-93.\u003c/li\u003e\n\u003cli\u003eWoodward SG, Rios-Diaz AJ, Zheng R, McPartland C, Tholey R, Tatarian T, et al. Finding the Most Favorable Timing for Cholecystectomy after Percutaneous Cholecystostomy Tube Placement: An Analysis of Institutional and National Data. J Am Coll Surg. 2021;232(1):55-64.\u003c/li\u003e\n\u003cli\u003ePavurala RB, Li D, Porter K, Mansfield SA, Conwell DL, Krishna SG. Percutaneous cholecystostomy-tube for high-risk patients with acute cholecystitis: current practice and implications for future research. Surg Endosc. 2019;33(10):3396-403.\u003c/li\u003e\n\u003cli\u003ede Mestral C, Gomez D, Haas B, Zagorski B, Rotstein OD, Nathens AB. Cholecystostomy: a bridge to hospital discharge but not delayed cholecystectomy. J Trauma Acute Care Surg. 2013;74(1):175-9; discussion 9-80.\u003c/li\u003e\n\u003cli\u003eLeveau P, Andersson E, Carlgren I, Willner J, Andersson R. Percutaneous cholecystostomy: a bridge to surgery or definite management of acute cholecystitis in high-risk patients? Scand J Gastroenterol. 2008;43(5):593-6.\u003c/li\u003e\n\u003cli\u003ePopowicz A, Lundell L, Gerber P, Gustafsson U, Pieniowski E, Sinabulya H, et al. Cholecystostomy as Bridge to Surgery and as Definitive Treatment or Acute Cholecystectomy in Patients with Acute Cholecystitis. Gastroenterol Res Pract. 2016;2016:3672416.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Acute cholecystitis, Percutaneous cholecystostomy tubes, cholecystograms, laparoscopic cholecystectomy, open cholecystectomy","lastPublishedDoi":"10.21203/rs.3.rs-6208563/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6208563/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAcute calculous cholecystitis is a common general surgical emergency and accounts for 20% of symptomatic gallstone presentations. According to the Tokyo Guidelines, the severity is stratified into mild, moderate, and severe. Percutaneous Cholecystostomy Drains (PCD) are a temporary intervention in acutely unwell patients with gallbladder disease. This study aims to assess the current utility of PCDs in a tertiary hepatobiliary referral centre.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective review of PCD patients treated in a tertiary hepatobiliary referral centre between January 2018 and December 2023. Clinical, radiological, and perioperative outcomes were measured. Descriptive analysis was performed using the GraphPad Prism program.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSixty-eight patients were identified over six years. The mean age was 71.6 years, with a male majority. The inpatient referral group had a higher rate of ASA IV score (43%, n=18) compared to the external referral group (39%, n=7) (p-value = 0.775). The most common diagnosis was severe cholecystitis with septic shock (33.8%), followed by gallbladder perforation (26.4%). Complications occurred in 4.4% of cases, and 61.7% of patients had a follow-up cholecystogram. The mean duration of PCT insertion was 95.78 days in our cohort. Completion cholecystectomy was performed in 87.1% of patients with ASA I-II and 40% with ASA III-IV (p value\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePercutaneous Cholecystostomy Drainage is a safe and effective procedure for managing acutely calculous cholecystitis. However, the significant heterogeneity in the literature regarding the management and follow-up guidelines of PCT for patients with severe cholecystitis calls for further research. Future studies should focus on establishing best practice guidelines for PCT follow-up, a crucial area that this study has identified for further exploration.\u003c/p\u003e","manuscriptTitle":"Cholecystostomy Drainage; Current Practices in a Tertiary Hepatobiliary Unit","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-10 15:13:16","doi":"10.21203/rs.3.rs-6208563/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"51bcc903-19a5-468b-97c0-b210fc9f9101","owner":[],"postedDate":"July 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":51216117,"name":"Health sciences/Diseases"},{"id":51216118,"name":"Health sciences/Diseases/Gastrointestinal diseases"},{"id":51216119,"name":"Health sciences/Gastroenterology/Gastrointestinal diseases"},{"id":51216120,"name":"Health sciences/Gastroenterology/Hepatology"},{"id":51216121,"name":"Health sciences/Gastroenterology/Hepatology/Biliary tract disease"}],"tags":[],"updatedAt":"2025-11-10T12:24:01+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-10 15:13:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6208563","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6208563","identity":"rs-6208563","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}