Percutaneous Gallstone Removal May Be an Option in High-Risk Symptomatic Patients

By Marilynn Larkin

October 16, 2020

NEW YORK (Reuters Health) - For patients with acute cholecystitis who are not candidates for surgery, cholecystostomy tube insertion followed by percutaneous cholecystolithotomy (PCCL) may be an option, researchers suggest.

Before PCCL can be performed, an interval of at least six weeks is required to allow a mature tract to form around the tube, thereby isolating the working tract from the peritoneal cavity and preventing potential spillage of fluid or stones.

"The procedure is vastly underutilized by interventional radiology departments across the globe as a means of eliminating gallstones and allowing patients who have had cholecystostomy tubes to become 'tube free,'" Dr. Eran Shlomovitz of UHN - Toronto General Hospital told Reuters Health by email.

"There is a proportion of patients who are either not surgical candidates for definitive cholecystectomy or for whom general anesthesia may be too risky," he said. "PCCL using either a flexible or rigid endoscope is a means to provide this subgroup of patients with definitive treatment and to avoid the potential complications of long-term cholecystostomy tube placement, while improving quality of life."

"While interventional radiologists have the catheter and wire skills required, very few are trained in biliary endoscopy," he noted. "With appropriate training, they can gain the endoscopic skills required to perform this procedure. Close collaboration between general surgery and interventional radiology is key to identify and treat this select group of patients."

As reported in the Journal of the American College of Surgeons, Dr. Shlomovitz and colleagues studied medical records of all 75 patients (mean age 75.6; 52% men) who underwent percutaneous gallbladder stone extraction at Toronto General Hospital between 2000-2017. Most (90.7%) were American Society of Anesthesia score 3 or 4 and 11 (14.7%) had failed prior cholecystectomy.

Forty-seven patients (62.6%) were at prohibitively high-risk for general anesthesia and underwent PCCL rather than cholecystectomy. Fifteen (20%) had technical concerns, such as extensive intraabdominal adhesions, and obliterated biliary anatomy. Eight (10.6%) had both high anesthetic risk and technical concerns. Five (6.6%) patients had advanced cirrhosis.

The mean follow-up time was 2.8 years.

Overall, 96 PCCL procedures were performed during the study period, and complete gallstone removal was achieved in 68 patients (90.7%), including all those with previously aborted cholecystectomy. The 30-day and 90-day readmission rates were 4% and 8%, respectively.

Clavien-Dindo grade I and II complications developed during 10 procedures (10.4%), and 17 patients (22.7%) had gallstone-related complications during follow-up. Three patients (3.9%) underwent cholecystectomy after PCCL.

Six patients (8%) developed post-procedural choledocholithiasis and five (6.3%) had recurrent gallstones (three undergoing cholecystectomy and two treated with a cholecystostomy tube).

The authors conclude, "PCCL is a viable option for management of symptomatic gallbladder stones in high-risk surgical patients. There is a high technical success rate, even in patients with prior failed cholecystectomy."

Dr. Prashant Sinha, Chief of Surgery at NYU Langone Hospital - Brooklyn commented in an email to Reuters Health, "It is striking that the procedure studied in this paper was performed only 96 times in 17 years. The authors also concede that it is not possible to know all of the possible complications that may have occurred to this group of patients. General anesthesia was used in almost half, indicating that these were not sick patients, but only had difficult anatomy."

"For patients who can have anesthesia and have difficult anatomy or scar tissue, we often use other techniques to complete gallbladder removal in order to take advantage of the excellent long-term outcomes," he noted.

"In the remaining patients who could not receive general anesthesia, it would be important to know how long they lived after the procedure," he said. "We find that patients who are too sick to undergo anesthesia may best be served with a temporary or even long-term drainage tube and antibiotics."

"We have had some successes with a new approach to endoscopically drain the gallbladder...and believe that this approach has many advantages to the percutaneous extraction, but also needs to continue being studied," he said.

"Percutaneous gallstone removal should best be studied with careful long-term monitoring, and with a quality of life assessment," he added. "I applaud the authors for presenting their data, but I would caution readers that retrospective data over a 17-year period does not offer compelling evidence to pursue what may be only a temporary solution, and may prevent some patients from receiving a more durable surgical solution."

SOURCE: Journal of the American College of Surgeons, online September 29, 2020.