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Systematic review of cholecystostomy as a treatment option in acute cholecystitis
Anders Winbladh1, Per Gullstrand, Joar Svanvik
1Department of Surgery, Faculty of Clinical and Experimental Medicine, Linköping University Hospital, Linköping, Sweden. anders.winbladh@lio.se
Insights
Percutaneous cholecystostomy (PC) is a treatment for acute cholecystitis in the elderly. Evidence does not support PC over cholecystectomy, and a randomized controlled trial is needed.
Area of Science:
- Gastroenterology
- Surgical Innovation
- Geriatric Medicine
Background:
- Percutaneous cholecystostomy (PC) is a recognized treatment for acute cholecystitis in elderly and critically ill patients.
- Cholecystectomy is the standard surgical procedure for acute cholecystitis.
Purpose of the Study:
- To review existing literature for evidence supporting percutaneous cholecystostomy (PC) over cholecystectomy for acute cholecystitis in the elderly.
- To identify the need for further research, specifically randomized controlled trials (RCTs).
Main Methods:
- A systematic electronic database search was conducted in April 2007.
- 53 studies comprising 1918 patients were included after exclusions.
- Analysis focused on mortality rates and treatment outcomes.
Main Results:
- Successful intervention rates for PC were 85.6%.
- 40% of PC patients underwent subsequent cholecystectomy with a 1.96% mortality rate.
- 30-day mortality was significantly higher for PC (15.4%) compared to cholecystectomy (4.5%).
Conclusions:
- No controlled studies directly compare PC and cholecystectomy outcomes in the elderly.
- Current evidence (Grade C) is insufficient to recommend PC over cholecystectomy.
- Recent low mortality rates for cholecystectomy in the elderly suggest an RCT is warranted.
Objectives:
Percutaneous cholecystostomy (PC) is an established low-mortality treatment option for elderly and critically ill patients with acute cholecystitis. The primary aim of this review is to find out if there is any evidence in the literature to recommend PC rather than cholecystectomy for acute cholecystitis in the elderly population.
Methods:
In April 2007, a systematic electronic database search was performed on the subject of PC and cholecystectomy in the elderly population. After exclusions, 53 studies remained, comprising 1918 patients. Three papers described randomized controlled trials (RCTs), but none compared the outcomes of PC and cholecystectomy. A total of 19 papers on mortality after cholecystectomy in patients aged >65 years were identified.
Results:
Successful intervention was seen in 85.6% of patients with acute cholecystitis. A total of 40% of patients treated with PC were later cholecystectomized, with a mortality rate of 1.96%. Procedure mortality was 0.36%, but 30-day mortality rates were 15.4 % in patients treated with PC and 4.5% in those treated with acute cholecystectomy (P < 0.001).
Conclusions:
There are no controlled studies evaluating the outcome of PC vs. cholecystectomy and the papers reviewed are of evidence grade C. It is not possible to make definitive recommendations regarding treatment by PC or cholecystectomy in elderly or critically ill patients with acute cholecystitis. Low mortality rates after cholecystectomy in elderly patients with acute cholecystitis have been reported in recent years and therefore we believe it is time to launch an RCT to address this issue.
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Assessment: