Management of Surgically High-Risk Patients With Acute Cholecystitis: A Comparative Retrospective Study of Percutaneous Cholecystostomy vs Endoscopic Retrograde Cholangiopancreatography Gallbladder Drainage

Introduction: Gallbladder drainage is essential for high-risk patients with acute cholecystitis (AC) who cannot undergo surgery. Percutaneous cholecystostomy (PC) and endoscopic retrograde cholangiopancreatography (ERCP) are commonly used for biliary drainage. This study compares the effectiveness and outcomes of PC and ERCP in patients with AC who are ineligible for surgery. Methods: Data were acquired from Marshall University hospitals, St Mary Medical Center and Cabell Huntington Hospital, Huntington, WV, from January 2019 to December 2022. AC patients deemed ineligible for cholecystectomy were classified into PC and ERCP groups. Chart reviews captured vital signs, lab results, comorbidities, surgical history, American Society of Anesthesiologists classification, and drainage procedure details. Outcomes assessed included technical and clinical successes, hospital mortality, 30-day mortality, unplanned procedures and hospital readmission within 30 days, post procedure complications (including luminal perforation, bile leak, stent/tube dislodgment, pancreatitis, bleeding, or infection), and length of stay (LOS). Chi-square test was used to examine categorical variables and t-test for continuous variables. Logistic regression model was built to adjust the differences between the groups. Results: The analysis included 157 patients, with 45 undergoing ERCP. ERCP patients were more likely to be younger, female, transferred from an outside facility, and have higher preoperative total bilirubin levels (Table 1). The unadjusted analysis showed lower LOS in the ERCP group but no other significant differences (Figure 1). Adjusted analysis revealed no differences in technical success (OR 0.15, 95% CI 0.01-1.91, P 0.13), clinical success (OR 0.5, 95% CI 0.2-1.22, P 0.13), hospital mortality (OR 0.63, 95% CI 0.09-3.43, P 0.61), 30-day mortality (OR 0.56, 95% CI 0.07-3.3, P 0.55), unplanned procedures (OR 1.82, 95% CI 0.55-5.82, P 0.32), procedure’s complications (OR 0.28, 95% CI 0.03-1.37, P 0.159) or hospital readmission (OR 0.53, 95% CI 0.19-1.36, P 0.2). However, the ERCP group had a significantly shorter mean LOS difference of -4.57 days (95% CI -8.8 to -0.34, P 0.036). Conclusion: This study provides a comprehensive comparison of PC and ERCP in treating patients with AC who were ineligible for cholecystectomy. ERCP may lead to a shorter hospital stay, but further prospective data is needed to inform clinical decision-making and expand the existing knowledge in this field.Figure 1.: Unadjusted outcome analysis comparing percutaneous cholecystostomy (PC) and endoscopic retrograde cholangiopancreatography (ERCP) for high-risk patients who were ineligible for surgery. Table 1. - Baseline Characteristics of the PC and ERCP Groups PC ERCP P Number of patients 112 45 Age (mean (SD)) 72.58 (14.94) 64.58 (17.78) 0.005 Female (%) 33 (29.5) 22 (48.9) 0.034 Race [White] (%) 111 (99.1) 44 (97.8) 1.000 Transfer from outside hospital (%) 24 (21.4) 18 (40.0) 0.029 BMI (mean (SD)) 31.10 (7.36) 28.59 (7.57) 0.057 Preoperative T-max (mean (SD)) 98.61 (1.01) 98.38 (0.58) 0.168 Preoperative heart rate (mean (SD)) 88.54 (16.67) 84.64 (17.30) 0.192 Preoperative SBP (mean (SD)) 127.56 (22.83) 132.36 (22.27) 0.233 Preoperative WBC (mean (SD)) 15.06 (9.53) 12.39 (6.05) 0.083 Preoperative alkaline phosphatase (mean (SD)) 187.05 (159.90) 309.98 (228.96) < 0.001 Preoperative total bilirubin (mean (SD)) 1.98 (2.92) 3.97 (4.77) 0.002 Preoperative lactic acid (mean (SD)) 1.90 (1.38) 2.57 (2.27) 0.094 Charlson comorbidity index (mean (SD)) 6.10 (2.65) 4.02 (3.21) < 0.001 Tobacco use (%) 0.979 No 64 (57.1) 26 (57.8) Active tobacco user 24 (21.4) 9 (20.0) Former tobacco user 24 (21.4) 10 (22.2) History of abdominal surgery (%) 61 (54.5) 29 (64.4) 0.335 ASA class (%) 0.154 I 1 ( 0.9) 1 ( 2.2) II 17 (15.2) 9 (20.0) III 68 (60.7) 22 (48.9) IV 26 (23.2) 11 (24.4) V 0 ( 0.0) 2 ( 4.4) Preoperative care (%) 0.068 Outpatient 16 (14.3) 2 ( 4.4) Floor 59 (52.7) 32 (71.1) ICU 37 (33.0) 11 (24.4) Use of preoperative pressors (%) 18 (16.1) 5 (11.1) 0.586 Time from admission to procedure [Days] (mean (SD)) 6.03 (9.98) 2.71 (3.94) 0.032