Cholecystostomy Audit

Background

The indications of cholecystostomy have been debated for a number of years and whereas traditionally they are employed for empyemas, the spectrum of use has increased. Severe acute cholecystitis has often been managed with a drain, especially in patients not fit for open operations but younger patients have also had them inserted. It has been used as a bridge to cholecystectomy especially in the septic patients.

A study from 2013 by Gurusamy et al has shown unequivocal evidence from two randomised trials of 156 patients. There was no change to mortality or morbidity in patients managed with cholecystostomy before an early laparoscopic cholecystectomy compared to a delayed cholecystectomy. They were unable to comment upon patients who were managed with a cholecystostomy compared to conservatively. Their conclusions were that they were unable to determine the role of cholecystostomy in patients with severe acute cholecystitis.

The updated Tokyo guidelines in 2013 recommended that a cholecystostomy only be employed in patients with moderate/severe cholecystitis who are unsafe for a surgical procedure. The guideline algorithm is as follows:

The evidence base for cholecystostomy use is weak and that is the fundamental basis of our audit with a view to developing guidelines and potentially a clinical trial.

Study Question

What are the indications for cholecystostomy, how are they managed and what proportions of patients have a cholecystectomy in the Mersey region?

Study Aim

To establish how cholcystostomies are inserted and managed regionally.

Using data obtained from this study and systematic review together with local expertise; formulate guidelines on indications and management of cholcystostomy.

Study Design

Initial regional retrospective audit of all cases managed between January 2015 and December 2017 in the Mersey region.

Parallel systematic review of literature with view to developing national guidelines.

Outcomes

Primary

• Indications of cholecystostomy insertion
• Management of cholecystostomy, specifically on removal and definitive gallbladder procedure

Secondary

• Length of stay (defined date of admission to date of discharge)
• Readmission rate (defined: all readmissions within 30 days of discharge)
• 30, 60, 90 day and in-hospital mortality
• Patient demographics (age, gender, presenting complaint, DM, cirrhosis)
• Indication of cholecystostomy
• Complication rate (defined by Clavien-Dindo classification
• Microbiology results
• Follow up investigations to manage removal of drain
• Surgical intervention, early, delayed or not at all

Steering Group