NAPLES, FLA. – Only fewer prior abdominal surgeries predicted successful laparoscopic gall bladder surgery after percutaneous cholecystostomy tube placement in a review of 245 patients.
Notably, the degree of illness at the time of percutaneous cholecystostomy tube (PCT) placement did not seem to influence the rate of laparoscopy, Dr. Mohammad Khasawneh reported at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
"Our data suggest that having three or more prior abdominal operations seemed to reliably lean toward conversion to an open cholecystectomy," he said in an interview.
Many patients with high operative morbidity and mortality risk developing cholecystitis and are treated with PCT drainage. Cholecystectomy after PCT placement is the definitive treatment for cholecystitis among patients whose risk profile improves, but it is unclear which patients will be able to have a laparoscopic cholecystectomy, explained Dr. Khasawneh, with the department of surgery at the Mayo Clinic, Rochester, Minn.
The investigators reviewed 245 patients who had a PCT placed at the clinic from 2009 to 2011. Their median age was 71 years, and two-thirds were male. Of these, 43 patients died, 131 were not surgical candidates, and 71 went on to interval cholecystectomy in a median of 55 days (range, 42-75 days).
Laparoscopy was planned for 63 patients (89%) and successfully completed in 50 (79%), with 13 converted to open surgery. Eight cases were originally planned for open surgery.
The high mortality rate after PCT placement (17.5%) was due to the presence of comorbid conditions, according to Dr. Khasawneh.
Index admission comorbidities among cholecystectomy and non-cholecystectomy patients were prior abdominal surgeries (44% vs. 55%, respectively), mechanical ventilation (8% vs. 16%), steroid use (8.5% vs. 15%), anticoagulation use (28% vs. 32%), vasopressor use (10% both), and dysrhythmia (23% vs. 27%).
Interval cholecystectomy patients had a significantly lower overall Charlson Comorbidity Index (5 vs. 6; P = .005) and spent significantly less time in the intensive care unit (3 vs. 7 days; P less than .01) and hospital (6 vs. 9 days; P less than .01), he reported.
In multivariable regression analysis, comorbidity index and number of prior abdominal operations significantly predicted interval cholecystectomy, whereas age (odds ratio, 1.1; P = .39), presence of stones (OR, 1.7; P = .11), and mechanical ventilation at the time of PCT drainage (OR, 0.55; P = .12) did not.
Only the number of prior abdominal operations significantly predicted laparoscopic cholecystectomy (OR, 0.52; P = .02), Dr. Khasawneh reported.
"Patients who are medically cleared for cholecystectomy should have an attempt at laparoscopic cholecystectomy unless they have multiple prior operations," the authors concluded.
Dr. Khasawneh and his coauthors reported having no financial disclosures.