Open Cholecystostomy Under Local Anesthesia for Acute Cholecystitis in the Elderly and High-Risk Surgical Patients

Key Takeaways

In critically ill elderly patients with cholecystitis, options beyond laparoscopic cholecystectomy should be considered.

Introduction

Approximately 6.5% of men and 10.5% of women have gallstone disease, and this incidence increases with age. By age 70, 15% of men and 24% of women have gallstones, and by the age of 90, these numbers increase to 24% and 35%, respectively.^1-3

A complication associated with gallstone disease is development of acute cholecystitis. Acute cholecystitis is one of the most frequent causes of admissions to surgical departments in Western countries. If not diagnosed and treated promptly, it can rapidly progress to a life-threatening complication such as empyema, gangrene, and perforation in 10-30% of patients. ⁴

Kimura et al report the mortality and complication rates of acute cholecystitis ranging between 0-10% and 7-26%, respectively. ⁵

The first laparoscopic cholecystectomy was performed in the mid-1980s. Many prospective trials have showed that laparoscopic cholecystectomy is a safe and effective treatment for acute cholecystitis with perioperative mortality rate between 0-0.3%. Therefore, it is considered the standard definitive treatment for this disease.^6-13 However, mortality rate increases dramatically to as high as 19%-30% when the operation is done in high-risk patients such as elderly or critically ill patients.^14,15

To assess the risk of general anesthesia in patients undergoing surgery, the American society of anesthesiologists (ASA) developed an evidenced-based tool, ASA classification, which has been shown to be a good predictor of perioperative morbidity and mortality.^16,17 It has been shown that urgent abdominal operations in patients older than 70 years old with an ASA score of III carry 30.6% mortality rate, and in patients older than 70 years old with an ASA score of IV carry 56.8% mortality rate.^18-21

Due to this significant increase in morbidity and mortality in critically ill patients and elderly with ASA score III and IV who undergo general anesthesia for emergency surgery, alternative treatments should be considered. Percutaneous cholecystostomy is a minimally invasive procedure that allows for immediate drainage and decompression of acutely inflamed gallbladder and can be used as a transient measure for decreasing inflammation and recovery from critical illness for patients not considered fit to undergo surgery and general anesthesia.^21,22

However, percutaneous techniques have associated complications and do not come without risk. Anders Winbladh et al in a systematic database search noted a 15.4% 30-day mortality in elderly patients with acute cholecystitis who underwent percutaneous cholecystostomy placement. An interval cholecystectomy was done in 40% of their patients with a mortality rate of 1.96%. ²¹

Percutaneous drainage of the gallbladder is not only a risk-free procedure, but also this technique is not considered a definitive treatment. After the emergency situation subsides and the patient recovers from acute illness, cholecystectomy, laparoscopic, or open, needs to be done in order to prevent recurrence of disease. Therefore, an alternative definitive treatment strategy will be ideal because performing even an elective procedure in the elder patient population may be hazardous.

An alternative to percutaneous cholecystostomy is to leave the acutely diseased gallbladder alone and only address the stones. Open cholecystostomy and cholecystolithotomy were first reported by Petit in 1743. ²³ The operation was made recognized by Marion Sims in 1878. ²⁴ This operation was the only method of treatment for acute cholecystitis for many years before Langenbuch performed the first open cholecystectomy in 1882.^25,26

Open cholecystolithotomy and cholecystostomy under local anesthesia is an attractive method in treating acute cholecystitis in elderly and severely ill patients. However, with the introduction of the laparoscopic cholecystectomy in the mid-1980s, many surgeons have questioned the utility of an open cholecystostomy in the current era.

We report a series of 5 cases of critically ill patients treated with open cholecystolithotomy and stone extraction under local anesthesia. Follow-up showed complete resolution of symptoms and lack of gallstone reformation on follow-up ultrasound.

Methods

Institutional review board approval was obtained prior to initiation of the study. A case series was performed on 5 patients who presented between August 2007 and April 2010. Inclusion criteria included high risk elderly patients who presented with acute cholecystitis and underwent open cholecystolithotomy and cholecystostomy tube placement.

Acute cholecystitis was determined based on Tokyo guidelines and/or imaging findings, including ultrasound and computed tomography. Findings on imaging included thickened gallbladder wall greater than 3 mm, pericholecystic fluid, and cholelithiasis or gallbladder sludge.

Demographics were noted and included age and ASA classification. Primary outcome was 30-day mortality. Secondary outcomes included intra- and immediate-postoperative complications, clinical improvement after drainage, additional biliary procedures needed, and outcome after cholecystostomy tube removal.

Results

Institutional Review Board approval was obtained prior to initiation of the study. Five patients were identified in our case series between the study period. Patients were between 83 and 92 years of age (mean 88.4). All patients were considered high risk for general anesthesia with ASA class of III or IV (4 patients were class III, and 1 patient was class IV). All patients (n = 5, 100%) were diagnosed with acute cholecystitis based on Tokyo guidelines or imaging findings; and on gross inspection intraoperatively, this was concordant. Two patients had empyema of the gallbladder with an associated pericholecystic abscess found in 1 patient. For these 2 patients, an intraperitoneal Jackson-Pratt drain was left in addition to the cholecytostomy Malecot drain.

We observed a 30-day mortality of 0% (n = 0) in our patients. None of the patients experienced an intraoperative complication (n = 0, 0%). Immediate postoperative complications, defined by postoperative complications until discharge from the hospital, were similarly 0% (n = 0). One patient underwent cardiac catheterization prior to surgery for presumed unstable angina and found to have inferior/septal ischemia; this patient was transferred to a tertiary center for coronary artery bypass surgery on postoperative day 1 from cholecystolithotomy and cholecystostomy tube placement.

Clinical improvement was observed in all 5 patients (n = 5, 100%), immediately after the surgery as determined by resolution of fever and pain and normalization of leukocytosis. None of our patients (n = 0, 0%) required emergency cholecystectomy for unresolved cholecystitis or continued sepsis.

Prior to their follow-up office visit, a cholecystogram through the tube was performed in all patients to ensure patency of the biliary ductal system. All the tubes were found to have normal bile drainage with no signs of infection prior to removal. All 5 patients had their cholecystostomy tubes removed in the office under local anesthetic between 23 and 29 days (mean 27 days) postoperatively.

There were no cases of biliary leakage or tube dislodgement or occlusion. There was no recurrence of acute cholecystitis within the mean follow-up of 20.75 months (18-35 months). None of our patients required cholecystectomy during the period of follow-up for recurrent acute cholecystitis.

Discussion

This group of 5 patients with acute cholecystitis who underwent open cholecystolithomy and cholecytostomy tube placement represents a highly selected series of patients who were severely ill as illustrated by ASA scores III and IV and older than the usual patient seen during the same period at our center.

Our complication and mortality rates are exceptionally low compared to previously published studies. However, it should be emphasized that the majority of these studies were published before late 1980s when laparoscopic cholecystectomy was being adapted as the procedure of choice in treating acute cholecystitis. It is difficult to find a similar series in the literature in the past 2 decades. It seems many surgeons in Western countries have abandoned this procedure as a viable option in treating acute cholecystitis. This partly is due to advancements in both laparoscopic instruments and ability of surgeons to perform those procedures but is also due to the influence of somewhat disappointing data from older literature.

In 1937, Liedberg presented a series of 20 open cholecystostomies performed for acute cholecystitis with mortality rate of 50%. ²⁷ This is an unacceptably high rate of mortality. However, care must be taken not to overlook the fact that this series was published more than 70 years ago. Improved operative techniques, new generation antibiotics, advancements in the prompt diagnosis, and care of critically ill patients need to be taken into consideration when applying these data into our modern surgical era.

To the best of our knowledge, the most recent report of open cholecystostomy and tube placement was published by Kaufman et al in 1990. ²⁸ He reports a series of 37 patients between 1974 and 1987 who underwent open cholecystostomy for acute cholecystitis with mortality rate of 5.4%.

The majority of these case series focused their attention to discover the underlying cause of mortality after open cholecystostomy for acute cholecystitis in critically ill patients. Most of the mortalities were attributed to ascending cholangitis and complications from general anesthesia.^29,30 In the past 2 decades, improved diagnostic criteria and advancements in imaging studies have facilitated the diagnosis and led to more prompt initiation of treatment in common bile duct obstruction and cholangitis.

With new local anesthetic medications and more advanced trained anesthesiology staff, operations under local anesthesia are well tolerated by the patients. In our series, all cases were performed under local anesthesia.

Open cholecystolithotomy and cholecystostomy tube placement were never considered a standard of treatment because of recurrence of stones and symptoms. Ideally, the diseased organ should be removed to eradicate the disease process and cure the illness. This can explain the unwillingness seen in surgeons in the past 2 decades to accept open cholecystostomy as a viable treatment option for critically ill patients.

What makes our data interesting is not only the low mortality rate but also our low recurrence rate. Our data suggest that open cholecystostomy, complete stone extraction, and gallbladder drainage via tube placement can be considered a definitive treatment modality in acutely ill elderly patients. This is especially important because even performing an interval elective cholecystectomy in an elderly patient with multiple medical comorbidities can be dangerous. However, reported recurrence rates in the literature are widely variable (0-69%).^29,30

We, after opening the gallbladder fundus, drained all the contents of the inflamed gallbladder and removed all the stones. Following, we proceeded to examine the gallbladder sac using finger examination and thoroughly evacuated all the stones and debris. Gallbladder inspection was completed by lavage with warm irrigation fluid to washout any remaining stone or debris. In our experience, this is the most important step in determining the long-term effectiveness of this procedure and recurrence rate. Complete stone extraction has not been emphasized in older literature and it is not clear whether it was done in all patients.

It should be emphasized that we first considered laparoscopic cholecystectomy as the procedure of choice in all our patients. However, upon further investigation, our patients were deemed too ill to undergo general anesthesia for laparoscopic or open cholecystectomy and we elected to proceed with open cholecystolithotomy as a salvage therapeutic measure. It is important to keep in mind that our patients were between 83 and 92 years of age (mean 88.4 yrs) and had multiple medical comorbidities. Life expectancy of this age group allows them to benefit from a less aggressive but definitive therapeutic strategy.

We certainly do not advocate open cholecystolithotomy and stone extraction as a first-line treatment strategy for acute cholecystitis. However, we believe this procedure should remain in any general surgeon’s armamentarium when it comes to deciding management strategies in severely ill and elderly patients. We are experiencing a gradual growth in the pool of older population with more comorbid conditions and they will benefit from less aggressive operations for times of acute severe illness.

Our report represents a small highly selected number of patients who were treated successfully with open cholecystolithotomy and tube placement and did not require further interventions in the future. This is an important contribution to the literature because it represents a modern experience of a somewhat abandoned procedure in Western countries.

Additional studies are required to determine which patients with acute cholecystitis benefit most from open cholecystolithotomy and to compare the outcomes, costs, and quality of life in high-risk surgical patients who receive this procedure vs other treatment modalities.