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Clinical Audit Clinical Audit
onon
EmergencyEmergency Percutaneous CholecystostomyPercutaneous Cholecystostomy
Interventional Radiology DivisionDepartment of Diagnostic RadiologyPamela Youde Nethersole Eastern Hospital
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OverviewOverview
BackgroundPercutaneous Cholecystostomy (PCC)Objectives of AuditResultsDiscussion
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BackgroundBackground
Acute cholecystitisManagement
Conservative vs. OperativeCholecystectomy vs. Percutaneous Cholecystostomy
Overseas experience Technical success rate (97-100%)Effectiveness (90-94%)Complication rate (3.3-16%)
Local experienceLi JC, Lee DW, Lai CW, Li AC, Chu DW, Chan AC. Percutaneous cholecystostomy for the treatment of acute cholecystitis in the critically ill and elderly. Hong Kong Med J. 2004 Dec;10(6):389-93.
RRAADDIIOOLLOOGGYY Schematic Diagram of PCC
Liver
GB
Chest Wall
Percutaneous CholecystostomyPercutaneous Cholecystostomy(PCC)(PCC)
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Percutaneous CholecystostomyPercutaneous Cholecystostomy
Indications:Critically ill or elderly patients with calculouscholecystitisAcute acalculous cholecystitis
Local AnesthesiaTechniques
Transhepatic approachTransperitoneal approach
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Ultrasound Guided Ultrasound Guided TranshepaticTranshepatic Puncture of Puncture of the the InflammedInflammed GallbladderGallbladder
GB
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CholecystogramCholecystogram
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Percutaneous CholecystostomyPercutaneous Cholecystostomy
Complication:Bile leakage resulting in peritonitisVagal effect of catheter placement (bradycardiaand hypotension)Hemobilia (usually transient and self-limiting)Mortality 3-36%
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Objectives of AuditObjectives of Audit
To assess the clinical parameters of the patients undergoing percutaneous cholecystostomy. To evaluate the technical aspects of percutaneous cholecystostomy. To follow up the patients after percutaneous cholecystostomy.
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Material & MethodsMaterial & Methods
Retrospective ReviewSelection criteria
All patients who underwent PCC from 01.06.2003 to 31.05.2005
Data retrieved from CMS and RIS
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Data CollectionData CollectionDemographics
AgeGenderDate & time of procedure
Clinical parametersAbdominal painBody temperatureHemodynamic StabilityBilirubin levelWCCPlatelet countINRRadiological diagnosis by modalityTime between radiological exam and PCC
Technical parametersImaging guidanceApproachCalibre of puncture needleUse of Exchange catheterSize of Fascial dilatrosDrainage catheter usedAnchorage of the catheterFentanyl usageTime of procedure
ResultTechnical resultBile cultureDeathTime between mortality and PCCComplicationBlood tests after PCCDuration of hospital stayOperation (Cholecystectomy)Time between operation and PCC
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DemographicsDemographics
Total 46 patients (M:F = 22:24) Mean age = 79.6 years (median = 80.0 years).
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Clinical PresentationClinical Presentation
58.7
78.2
33.3
79.3
100.0
0 25 50 75 100
Elevated Bilirubin
Elevated WCC
Septic Shock
Fever
Pain
Percentage
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Radiological Diagnosis by ModalityRadiological Diagnosis by Modality
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Technical Aspects of Technical Aspects of Percutaneous Percutaneous CholecystostomyCholecystostomy
All procedures performed under ultrasound and fluoroscopic guidance Transhepatic approach - 34 patients (73.9%) Transperitoneal approach - 6 patients (13.0%)Time of procedure (mean = 27minutes)
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ResultsResults
Technically successful PCC in 100%Positive bile culture in 32/45 (71.1%)Rapid clinical improvement in 41/46 patients (89.1%)Duration of hospital stay - 15 days (median) Elective cholecystectomy performed in 11 patients (23.9%).
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Result Result -- ComplicationComplication
Catheter displacement: 3 patients (6.5%).
1 Reinsertion 2 Treated conservatively
Time of occurenceBetween 3 days – 1 week in 1patient> 1 week in 2 patients
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Result Result -- MortalityMortality
Deaths in 6 patients (10.5%) and all are not related to the procedureUncontrolled sepsis in 2 patients
Patient 1 (M/65)Refused cholecystectomyKlebsiella (Resistant to Ampicillin, Cefazolin, Cefoxitin Cefuroxime)Given Tazocin, Metronidazole
Patient 2 (M/79)Disseminated intravascular coagulopathy at presentation
Other medical conditions in 4 patients
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Discussion: ComparisonDiscussion: Comparison
28%Median 22d
20%16%(minor)
92%100%25Li
90%
94%
90%
89.1%
Clinical Response
30
16
65
46
No. of Patients
90%--3.3%(minor)
100%Ito
44%-18%18%(1 major)
94%Teoh
15.3%Mean 15d13.8%No major ones
97%Welschbillig
23.9%Median 15d
10.5%6.5%(minor)
100%PYNEH
Elective cholecystec-
tomy
Duration of stayDeathsComplicationTechnical
ResultAuthors
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ConclusionConclusion
Our results are comparable with overseas and local data.Percutaneous Cholecystostomy is a safe and effective treatment of acute cholecystitis with high success and low complication rates. It can also minimize the morbidity and mortality relating to the complications from emergency operation on those critically ill patients, as cholecystectomy can be arranged on an elective basis after the patient's condition improves.
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ReferencesReferences
Li JC, Lee DW, Lai CW, Li AC, Chu DW, Chan AC. Percutaneous cholecystostomy for the treatment of acute cholecystitis in the critically ill and elderly. Hong Kong Med J. 2004 Dec;10(6):389-93.Welschbillig-Meunier K, Pessaux P, Lebigot J, Lermite E, Aube Ch,Brehant O, Hamy A, Arnaud JP. Percutaneous cholecystostomy for high-risk patients with acute cholecystitis. Surg Endosc. 2005 Sep;19(9):1256-9. Epub 2005 Jul 14.Teoh WM, Cade RJ, Banting SW, Mackay S, Hassen AS. Percutaneous cholecystostomy in the management of acute cholecystitis. ANZ J Surg. 2005 Jun;75(6):396-8. Ito K, Fujita N, Noda Y, Kobayashi G, Kimura K, Sugawara T, Horaguchi J. Percutaneous cholecystostomy versus gallbladder aspiration for acute cholecystitis: a prospective randomized controlled trial. AJR Am J Roentgenol. 2004 Jul;183(1):193-6.