Ultrasound guided percutaneous cholecystostomy in high-risk patients for surgical intervention

AIM: To assess the efficacy and safety of ultrasound guided percutaneous cholecystostomy (PC) in the treatment of acute cholecystitis in a well-defined high risk patients under general anesthesia. METHODS: The data of 27 consecutive patients who underwent percutaneous transhepatic cholecystostomy for the management of acute cholecystitis from January 1999 to June 2003 was retrospectively evaluated. All of the patients had both clinical and sonographic signs of acute cholecystitis and had comorbid diseases. RESULTS: Ultrasound revealed gallbladder stones in 25 patients and acalculous cholecystitis in two patients. Cholecystostomy catheters were removed 14-32 d (mean 23 d) after the procedure in cases where complete regression of all symptoms was achieved. There were statistically significant reductions in leukocytosis, (13.7 × 103 ± 1.3 × 103 μg/L vs 13 × 103 ± 1 × 103 μg/L, P < 0.05 for 24 h after PC; 13.7 × 103 ± 1.3 × 103 μg/L vs 8.3 × 103 ± 1.2 × 103 μg/L, P < 0.0001 for 72 h after PC), C -reactive protein (51.2 ± 18.5 mg/L vs 27.3 ± 10.4 mg/L, P < 0.05 for 24 h after PC; 51.2 ± 18.5 mg/L vs 5.4 ± 1.5 mg/L, P < 0.0001 for 72 h after PC), and fever (38 ± 0.35℃ vs 37.3 ± 0.32℃, P < 0.05 for 24 h after PC; 38 ± 0.35℃ vs 36.9 ± 0.15℃, P < 0.0001 for 72 h after PC). Sphincterotomy and stone extraction was performed successfully with endoscopic retrograde cholangio-pancreatography (ERCP) in three patients. After cholecystostomy, 5 (18%) patients underwent delayed cholecystectomy without any complications. Three out of 22 patients were admitted with recurrent acute cholecystitis during the follow-up and recoveredwith medical treatment. Catheter dislodgement occurred in three patients spontaneously, and two of them were managed by reinsertion of the catheter. CONCLUSION: As an alternative to surgery, percutan- eous cholecystostomy seems to be a safe method in critically ill patients with acute cholecystitis and can be performed with low mortality and morbidity. Delayed cholecystectomy and ERCP, if needed, can be performed after the acute period has been resolved by percutaneous cholecystostomy.

Percutaneous Cholecystostomy in High Risk Patients with Acute Cholecystitis

Aims and Objectives: To assess efficacy and safety of percutaneous cholecystostomy (PC) in high risk patients with acute cholecystitis. Materials and Methods: The study was carried out in high risk patients with acute calculous or acalculous cholecystitis. Patients qualifying for the study were subjected to PC under ultrasound (USG) guidance. A cholecystogram was done postoperatively, to help establish satisfactory catheter position. Results: 24 (70.59%) patients had empyema-gallbladder, 8 (23.53%) had acute calcular cholecystitis and 2 (5.9%) patients were diagnosed as acalcular cholecystitis. None of the patients was fit for general anesthesia at the time of admission. Median hospital-stay after performing procedure was 4 days. Clinical success rate was reported 100% in our study. Bile cultures yielded growth of E Coli in 10 (29.41%), klebsela in 8 (23.53%), pseudomonas aeruginosa in 6 (17.65%) and Proteus mirabilis in 4 (11.8%) of patients. 6 (17.65%) patients did not grow any organism in their bile. Growth noted was sensitive to imipenem 29.41% (10), ciprofloxacin 17.65% (6), levofloxacin 17.65% % (6) and cefuroxime 11.76% (4). No major complication was recorded in our study. No procedure related death was observed. Tube displacement occurred in one patient and minor bleeding was reported in 2 patients. Catheter was removed after a mean of 25.25 days. All patients underwent definitive surgical intervention during the follow up period of 3 months. Conclusion: USG guided PC is a safe and effective procedure for treating high-risk patients who present with acute cholecystitis. Once the acute symptoms diminish or resolve, it should be followed by elective surgery.

Efficacy and safety of conversion of percutaneous cholecystostomy to endoscopic transpapillary gallbladder stenting in high-risk surgical patients

Background:Endoscopic transpapillary gallbladder stenting(ETGBS)has been used as an alternative to percutaneous cholecystostomy in patients with acute cholecystitis who are considered unfit for surgery.However,there are few data on the efficacy and safety of ETGBS replacement of percutaneous cholecystostomy in high-risk surgical patients.This study aimed to evaluate the feasibility,efficacy,and safety of ETGBS to replace percutaneous cholecystostomy in high-risk surgical patients.Methods:This single center retrospective study reviewed the data of patients who attempted ETGBS to replace percutaneous cholecystostomy between January 2017 and September 2019.The technical success,clinical success,adverse events,and stent patency were evaluated.Results:ETGBS was performed in 43 patients(24 male,mean age 80.7±7.4 years)to replace percutaneous cholecystostomy due to high surgical risk.The technical success rate and clinical success rate were 97.7%(42/43)and 90.5%(38/42),respectively.Procedure-related adverse events and stent-related late adverse events occurred in 7.0%(3/43)and 11.6%(5/43),respectively.Of the patients who successfully underwent ETGBS(n=42),only one had recurrent acute cholecystitis during follow-up.The median stent patency was 415 days(interquartile range 240–528 days).Conclusions:ETGBS,as a secondary intervention for the purpose of internalizing gallbladder drainage in patients following placement of a percutaneous cholecystostomy,is safe,effective,and technically feasible.Thus,conversion of percutaneous cholecystostomy to ETGBS may be considered as a viable option in high-risk surgical patients.

UG-PTGD治疗对老年急性胆囊炎患者疼痛程度的影响

目的探究超声引导下经皮经肝胆囊穿刺置管引流术(Ultrasound Guided Percutaneous Transhepatic Gall bladder Drainage,UG-PTGD)治疗对老年急性胆囊炎患者疼痛程度的影响。方法选取江阴市中医院于2020年3月—2023年6月收治的93例老年急性胆囊炎患者为研究对象,按治疗方式不同分为对照组(46例)、观察组(47例)。对照组予以胆囊造瘘术治疗,观察组行UG-PTGD治疗。手术完成后,对比两组围术期指标、术后疼痛程度及炎性因子水平。结果观察组术中出血量、手术时间、拔管时间、排气时间及下床时间均优于对照组,差异有统计学意义(P均<0.05)。观察组术后即刻、术后第3天、第7天视觉模拟评分(Visual Analog Scale,VAS)为(1.29±0.31)分、(5.03±1.41)分和(3.54±0.54)分,均低于对照组,差异有统计学意义(t=3.872、2.106、2.980,P均<0.05)。观察组白细胞计数(White Blood Cell Count,WBC)、白细胞介素-6(Interleukin-6,IL-6)、C反应蛋白(C-reactive Protein,CRP)水平均低于对照组,差异有统计学意义(P均<0.05)。结论针对老年急性胆囊炎患者,采取UG-PTGD治疗具有一定手术操作优势,有助于降低患者的炎性因子水平,且减轻患者术后的疼痛程度。

Call for action:Increased healthcare utilization with growing use of percutaneous cholecystectomy tube over initial cholecystectomy in cirrhotics

Background:Acute calculous cholecystitis(ACC)is frequently seen in cirrhotics,with some being poor candidates for initial cholecystectomy.Instead,these patients may undergo percutaneous cholecystostomy tube(PCT)placement.We studied the healthcare utilization and predictors of cholecystectomy and PCT in patients with ACC.Methods:The National Database was queried to study all cirrhotics and non-cirrhotics with ACC between 2010-2014 who underwent initial PCT(with or without follow-up cholecystectomy)or cholecystectomy.Cirrhotic patients were divided into compensated and decompensated cirrhosis.Independent predictors and outcomes of initial PCT and failure to undergo subsequent cholecystectomy were studied.Results:Out of 919189 patients with ACC,13283(1.4%)had cirrhosis.Among cirrhotics,cholecystec-tomy was performed in 12790(96.3%)and PCT in the remaining 493(3.7%).PCT was more frequent in cirrhotics(3.7%)than in non-cirrhotics(1.4%).Multivariate analyses showed increased early readmis-sions[odds ratio(OR)=2.12,95%confidence interval(CI):1.43-3.13,P<0.001],length of stay(effect ratio=1.39,95%CI:1.20-1.61,P<0.001),calendar-year hospital cost(effect ratio=1.34,95%CI:1.28-1.39,P<0.001)and calendar-year mortality(hazard ratio=1.89,95%CI:1.07-3.29,P=0.030)in cir-rhotics undergoing initial PCT compared to cholecystectomy.Decompensated cirrhosis(OR=2.25,95%CI:1.67-3.03,P<0.001)had the highest odds of getting initial PCT.Cirrhosis,regardless of compensated(OR=0.56,95%CI:0.34-0.90,P=0.020)or decompensated(OR=0.28,95%CI:0.14-0.59,P<0.001),reduced the chances of getting a subsequent cholecystectomy.Conclusions:Cirrhotic patients undergo fewer cholecystectomy incurring initial PCT instead.Moreover,the rates of follow-up cholecystectomy are lower in cirrhotics.Increased healthcare utilization is seen with initial PCT amongst cirrhotic patients.This situation reflects suboptimal management of ACC in cirrhotics and a call for action.

Percutaneous Cholecystomy Guided by Ultrasound for Acute Cholecystitis in High-risk Aged Patients

Objective The aim of the present study was to assess experience with percutaneous cholecystostomy (PC) in high risk aged patients with presumed acute cholecystitis. Methods\ PC was performed by transhepatic route under local anaesthesia guided by ultrasonography cholecystostomy catheters. The catheters used include the Cope loop(produced by Japan hakko). Results\ PC was performed successfully in all 18 patients, without immediate procedural or technical complications. Symptoms and clinical signs of cholecystitis resolved within 24 48 h after the procedures in all but one patient. Conclusion\ PC is a cost effective ,mini invasive, and reliable alternative to surgical placement of cholecystostomy tubes in critically ill patient. This study also can be used in hepatic abscess, obstructive jaundice and necrostic pancreatitis caused by stone or tumor.\;

B超导引下经皮经肝胆囊穿刺造瘘术治疗急性胆囊炎的效果评价

目的研究经B超引导下经皮经肝胆囊穿刺造瘘术治疗急性胆囊炎的效果。方法72例急性胆囊炎患者,随机分为观察组和对照组,各36例。对照组通过常规的腹腔镜下胆囊切除术治疗,观察组通过B超引导下经皮经肝胆囊穿刺造瘘术治疗。比较两组临床疗效、恢复指标。结果观察组治疗总有效率94.44%高于对照组的75.00%,差异有统计学意义(P<0.05)。观察组术中出血量(54.06±4.62)ml少于对照组的(66.47±5.46)ml,手术时间(63.46±10.35)min、术后住院时间(6.67±2.16)d短于对照组的(94.38±12.36)min、(10.34±3.06)d,差异有统计学意义(P<0.05)。结论临床通过B超引导下经皮经肝胆囊穿刺造瘘术治疗急性胆囊炎的效果显著,可促进患者的恢复,值得推荐。

X线下经皮胆囊穿刺引流治疗急性重症胆囊炎31例分析

目的评价X线下经皮经肝胆囊穿刺引流术治疗急性重症梗阻性胆囊炎患者的临床疗效和治疗经验。方法对2006年1月-2008年12月31例急性重症梗阻性胆囊炎患者行X线引导下的经皮经肝胆囊穿刺引流术治疗,通过对比术前、术后实验检查及临床症状的改善评价疗效。结果31例患者均成功置入引流管,未发生相关并发症。1例合并急性肾功能衰竭患者死亡,其余30例患者症状缓解并带管出院。16例结石性胆囊炎患者于术后1～3个月行择期胆囊切除术,8例结石性胆囊炎患者选择带管生存,6例非结石性胆囊炎患者于胆囊炎治愈后3周至6周拔管。结论X线下经皮胆囊穿刺引流术操作简便、创伤小、安全性高,是急性重症胆囊炎患者的一种过渡治疗,甚至是终末治疗方法。

经皮胆囊穿刺造瘘处理高危急性胆囊炎53例分析

目的评价B超引导下经皮胆囊穿刺造瘘(percutaneous cholecystostomy,PC)处理高危急性胆囊炎患者的有效性和治疗经验。方法回顾性分析1999年1月至2005年8月接受PC治疗的53例高危急性胆囊炎患者的临床资料。结果53例均穿刺置管成功,4例因引流管脱落或堵塞而再次行PC。52例(98.1%)获得有效的胆囊引流,1例患者(1·9%)术后病情转坏,术后1d行了紧急胆囊切除术。41例于急性胆囊炎治愈后2周至3个月行择期胆囊切除术,全组无1例因经皮胆囊穿刺引流术引起的并发症死亡。随访分别达6个月至3年。结论经皮胆囊穿刺造瘘术是治疗高危急性胆囊炎患者的一项安全、简便、有效的方法。它有较高的成功率和较低的并发症。

CT引导下经皮胆囊造瘘治疗急性非结石性胆囊炎

目的探讨CT引导下经皮胆囊造瘘治疗急性非结石性胆囊炎的技术要点和临床疗效。方法回顾性分析CT引导下经皮胆囊造瘘治疗46例的急性非结石性胆囊炎患者的临床表现、置管成功率、并发症及临床疗效。结果46例患者均1次置管成功（技术成功率100％），无严重并发症发生。引流术后所有患者临床症状均有好转，随访1～23个月，25例顺利拔管，9例带管死于与胆囊炎无关疾病，余12例长期带管生存。结论CT引导下经皮胆囊造瘘治疗急性非结石性胆囊炎安全有效。

118例经皮胆囊穿刺治疗危急重症胆囊炎及序贯治疗和预后分析

目的探讨经皮胆囊穿刺引流治疗危急重症胆囊炎的疗效以及后续序贯治疗方案选择。方法回顾性分析2010年1月至2015年12月北京市普仁医院收治的118例危急重症胆囊炎行胆囊穿刺引流患者的临床资料,总结患者穿刺后恢复、后续的胆囊切除手术方式、序贯治疗以及患者预后情况。结果 118例行胆囊穿刺治疗,102例患者病情好转后出院,死亡16例;后续行胆囊切除术83例,7例非结石性胆囊炎,好转后拔除胆囊引流,12例评估后仍无法耐受麻醉及手术,长期带管。16例患者首次穿刺期间死亡,死亡原因主要为心肺功能不全,其中80岁以上并发症严重患者占75%。结论经皮肝穿胆囊引流是一种相对安全有效的方法,但是对于一些高龄患者即使行穿刺治疗,因全身情况复杂,术后恢复仍有较大风险,胆囊穿刺后续治疗应针对发病的不同特点及全身状况做好评估,做出更适宜的治疗方案。

B超定位胆囊穿刺造瘘术治疗高龄急性胆囊炎78例报告

目的：探讨B超定位胆囊穿刺造瘘术对高龄急性胆囊炎患者的疗效。方法：分析2003—08～2006—08我科以B超定位胆囊穿刺造瘘术治疗的78例高龄（≥70岁）急性胆囊炎患者的临床资料，78例入院前合并各种疾病者72例（92．3％）。结果：78例全部成功施行穿刺造瘘（100％），无出血、胆瘘等并发症发生，74例治愈出院（94．9％），4例（5．1％）死亡，出院51例（65．4％）3个月后行腹腔镜胆囊切除，术后患者恢复好。结论：B超定位胆囊穿刺造瘘可迅速缓解高龄患者急性胆囊炎引起的危急症状，避免急诊开腹手术带来的风险，具有微创、方便、安全等优势，可明显降低死亡率，值得推广。

经皮经肝胆囊穿刺术在术后早期炎性肠梗阻并发淤胆治疗中的应用

目的禁食、全胃肠外营养(total parenteral nutrition,TPN)时间长及应用生长抑素治疗,引起少数术后早期炎性肠梗阻(early postoperative inflammatory ileus,EPII)患者出现淤胆症状。文中探讨经皮经肝胆囊穿刺术(percutaneous transhe-patic cholecystostomy,PTC)在术后EPII并发淤胆患者中的应用价值。方法回顾性分析15例腹部手术后EPII并发淤胆患者运用PTC的治疗效果。患者均行B超或腹部CT检查,常规进行禁食、胃肠减压、灌肠、TPN、生长抑素、小剂量糖皮质激素等综合治疗,运用PTC行胆汁外引流。结果 15例患者均非手术治愈,无穿刺并发症发生,平均住院时间为(32.5±5.7)d,TPN支持时间平均为(26.6±10.5)d,穿刺后至肛门排气为1～4 d,平均时间为(2.3±0.9)d。11例患者谷丙转氨酶(GPT)、谷草转氨酶(GOT)、γ-谷氨酰转肽酶(γ-GT)、碱性磷酸酶(AKP)、总胆红素、直接胆红素水平升高,穿刺后GPT、GOT、γ-GT、AKP、总胆红素、直接胆红素水平较快恢复正常,淤胆症状消失。6例患者出现低热、右上腹不适症状,穿刺后体温恢复正常,右上腹不适症状缓解。结论 PTC运用安全有效,虽不能根本改变术后EPII的病理过程,但能明显改善术后患者因禁食而长期应用TPN导致的淤胆症状,改善肝功能,恢复胆汁流,促进肠蠕动,加速康复。

超声引导下经皮胆囊穿刺引流术治疗急性重症胆管炎31例临床分析

目的：探讨超声引导下经皮胆囊穿刺引流术治疗急性重症胆管炎的临床疗效和应用价值。方法对31例急性重症胆管炎患者治疗采用超声引导下经皮胆囊穿刺引流术。结果超声引导下经皮胆囊穿刺引流成功率为100％，无出血、胆漏及副损伤等相关并发症。术后1例死于多器官衰竭，另外30例临床症状快速缓解、全身情况显著改善。术后2～6周，根据患者的情况分别施行不同的二期手术，术后均康复出院。结论经皮胆囊穿刺引流术具有操作简便、微创、安全等优点，适用于伴有胆囊肿大的急性重症胆管炎患者的过渡性治疗，为二期手术治疗创造良好的条件。

急性非结石性胆囊炎的诊断与治疗

目的探讨急性非结石性胆囊炎的诊断及治疗方法。方法结合国内外相关文献,对近年来本院收住的41例急性非结石性胆囊炎患者临床资料进行回顾性分析。结果41例急性非结石性胆囊炎患者经过个性化治疗后,39例治愈,2例死亡。结论急性非结石性胆囊炎是一种相对独立的临床疾病,其重症患者并发症率和病死率高,早期诊断及个性化治疗是提高疗效的关键,对于不能耐受手术的患者,B超引导下经皮胆囊穿刺造瘘,是一种有效、安全可靠、操作简便且花费较少的治疗手段。

双介入治疗糖尿病足的临床研究

目的:探讨经皮腔内成形术(PTA)联合经皮动脉穿刺导管药盒系统(PCS)治疗糖尿病足的临床疗效。方法:60例糖尿病足患者,行PTA术治疗后,再于皮下植入动脉药盒系统,并经动脉连接导管系统行前列地尔注射液、丹参注射液灌注治疗。14天为1疗程,共治疗2个疗程。治疗前后测定踝臂指数(ABI)。结果:全部糖尿病足患者,治愈38例,有效20例,无效2例,总有效率96.7%。治疗前ABI为0.32±0.11,治疗后ABI为0.76±0.14,(治疗前后比较P=0.000)。结论:PTA联合PCS灌注药物对糖尿病足有明显治疗作用,疗效满意,能有效改善下肢血液循环。

针刺麻醉应用于经皮椎体后凸成形术疗效观察

目的观察电针在经皮椎体后凸成形术(PKP)中应用的镇痛效果。方法 60例行PKP患者,随机分成电针组和对照组,每组30例。电针组在电针加局麻麻醉方法下进行手术;对照组仅在局麻下进行手术。观察两组患者手术前与手术中MAP和HR的变化以及手术前、手术后4 h、手术后24 h的VAS评分差异。结果两组患者手术后4 hVAS评分均比手术前明显下降(P<0.01);电针组术后4 hVAS评分较对照组稍低,但无显著性差异(P>0.05);电针组手术后24 hVAS评分比术后4 h有显著性下降(P<0.05);对照组术后24 hVAS评分较术后4 h无明显下降。电针组术后24 hVAS评分较对照组也有显著性下降(P<0.01)。两组手术中MAP均比手术前升高(P<0.05);电针组手术中和手术前HR无明显变化;对照组手术中HR比手术前明显升高(P<0.01)。结论 电针加局部麻醉在PKP的围术期有缓解疼痛,稳定心率,提高手术耐受性的作用。

经皮胆囊造瘘治疗老年重症急性胆囊炎的体会

目的 探讨急诊B超引导下经皮经肝胆囊造瘘治疗老年重症急性胆囊炎的价值。方法 对 2 8例 70岁以上重症急性胆囊炎患者行B超引导下经皮胆囊造瘘并结合内窥镜治疗。结果 2 7例造瘘成功 ,平均 2天后症状缓解 ;胆道造影显示 8例伴有总胆管结石 ,其中 7例行ERCP取石并获成功 ;造瘘后 16例行腹腔镜胆囊切除 ,12例行开腹手术 ,总病死率 3.7%。结论 急诊B超引导下经皮经肝胆囊造瘘结合内镜治疗总胆管结石 ,然后进行胆囊切除术是治疗老年重症急性胆囊炎的好方法。

梗阻性黄疸的处置和经皮直接穿刺胆囊造口的价值

本文报告应用经皮胆囊穿刺造口术治疗40例梗阻性黄疸患者的结果,并与同时期施行的经皮经肝胆管穿刺引流40例在成功率、引流效果及并发症诸方面做比较。作者认为,前者具有操作简便、创伤小、引流满意、并发症少等优点而建议推广应用。应用扩张导管进行胆囊置管不会发生胆汁渗漏。但是对于高位胆道梗阻、胆囊管闭塞和胆囊萎缩者,本法仍不能取代经皮经肝胆管穿刺引流。

双重超声造影在经皮经肝胆囊造瘘术后并发症评估中的应用

目的探讨多种给药途径超声造影评估胆囊造瘘术后并发症发生的原因并指导临床进行相应处理方法选取2015年6月至2020年6月胆囊造瘘患者398例中术后出现腹痛及引流管引流不畅的患者33例,男21例,女11例;年龄23〜98岁,平均年龄(72.37±8.32)岁。分别进行常规超声及超声造影检查,比较两种方法的确诊率结果二维超声发现肝周积液和肝包下血肿2例,引流管末端位置偏移8例,余23例二维超声未发现异常,确诊率30.3%;经静脉超声造影提示肝脏、胆囊活动性出血2例,肝周积液及包膜下血肿3例,管道超声造影提示引流管滑脱、移位及堵塞20例,余8例双重造影均未发现异常,确诊率75.76%,两者比较差异有统计学意义(P<0.05)结论双重超声造影可以有效评估胆囊造瘘术后并发症,指导临床及时对症处理,在临床实践中有较高的应用价值。