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11
SURGERY
EFFICACY OF PERCUTANEOUS TRANSHEPATIC CHOLECYSTOSTOMY IN ACUTE OBSTRUCTIVE CHOLECYSTITIS
Ospan Zh.R.1, Doskhanov M.O.12, Serikuly E.2, Mukazhanov D.Y2., Hadjieva A.A.1, Tileuov S.T.2, Skakbayev A.S.2, Askeev B.T.2, Baimakhanov Zh.B.12, Kaniyev Sh.A.12, Chormanov A.T.2, Baimakhanov B.B.21, Seisembayev M.A.2
1 "S.D.Asfendiyarov Kazakh National Medical University" NC JSC, Almaty, Kazakhstan
2 "A.N. Syzganov National Scientific Center of Surgery" JSC, Almaty, Kazakhstan
Abstract
Acute obstructive cholecystitis is a common disease with a significant risk of mortality and complications. Active surgical tactics, such as open and laparoscopic access, pose a significant risk for elderly patients with concomitant diseases on the background of acute cholecystitis. The aim of our study is to analyze the effectiveness of percutaneous transhepatic cholecystostomy (PTCS) in acute obstructive cholecystitis (AOC) and subsequent laparoscopic cholecystectomy (LCE).
Materials and methods. Retrospectively, we analyzed 64 patients treated with AOC in the period from 2017 to 2021 at the NSCS named after A.N. Syzganov. We divided them into 2 groups depending on surgical treatment. The first group: patients who were performed PTCS (n=29) at the first stage. The second stage, LCE was performed during the waiting period from 3 days to 72 days. The second group: patients who underwent LCE without drainage of the gallbladder (n=35). Also, the patients of the first group were divided into 3 subgroups depending on the waiting time: group A - LCE was performed within 10 days after PTCS, subgroup B - LCE was performed after from 2 to 4 weeks (n=12), patients of the subgroup C, LCE were performed after 4 weeks after PTCS. Preoperative, intraoperative data and postoperative complications were analyzed.
Results. According to preoperative data, there was no significant difference in body temperature, laboratory data and concomitant diseases. The statistical difference was revealed only in the age of patients (65.3±9.0 vs 53.4±15.4). The duration of the operation in the second group of LCE was longer compared to the first group, but no significant difference was detected (108.1 ± 30.5 vs 117.9 ± 39.9). In the postoperative period after LCE, complications were observed in 5 (14.2%) cases: bleeding in 4 (11.4%) cases and suppuration of the postoperative wound in 1 (2.8%) case. Conversion was performed in 10 (15.6%) cases, and in one (1.5%) case, the choledochal wall was injured intraoperatively. There was no significant difference between groups A, B and C.
Conclusion.The use of two-stage treatment significantly reduces the conversion to open surgery, significantly reduces postoperative complications and hospital stay in the postoperative period. According to the results of our research, the most optimal interval between PTCS and LCE is a period of more than 4 weeks.
https://doi.org/10.35805/BSK2022IV005
Ospan Zh.R.
orcid.org/0000-0001-Doskhanov M.O. orcid.org/0000-0002-Serikuly E. orcid.org/0000-0002-Mukazhanov D.Y. orcid.org/0000-0001-Hadjieva A.A. orcid.org/0000-0002-Tileuov S.T. orcid.org/0000-0003-Skakbayev A.S. orcid.org/0000-0003-Askeev B.T. orcid.org/0000-0002-Baimakhanov Zh.B orcid.org/0000-0003-Kaniyev Sh.A. orcid.org/0000-0002-Chormanov A.T. orcid.org/0000-0003-Baimakhanov B.B. orcid.org/0000-0002-Seisembayev M.A. orcid.org/0000-0002-
■6803-5806 ■8578-8567 ■3423-9533 ■5742-2691 4431-4488 1786-0720 ■0372-068X ■3695-7811 1887-7866 1288-0987 ■3513-1935 9839-6853 1072-1675
Corresponding author. Ospan Zh.R. - Resident of 2 year of training in the specialty «General Surgery» of «S.D. Asfendiyarov KazNMU» NC JSC, Almaty, Kazakhstan E-mail: jambyl97@mail.ru
Conflict of interest
The authors declare that they have no conflicts of interest
Keywords:
Acute obstructive cholecystitis, Percutaneous transhepatic cholecystostomy Laparoscopic cholecystectomy, Gallstone disease
Жедел обструктивт холецистит кезшде Tepi жэне бауыр аркылы ететш холецистостомияньщ тшмдшт
Оспан Ж.Р.1, Досханов М.О.1,2, Сершулы Е.2, Мукажанов Д.Е.2, Хаджиева А.А.1, Тилеуов С.Т.2, Скакбаев А.С.2, Аскеев Б.Т.2, Баймаханов Ж.Б.12, Каниев Ш.А.12, Чорманов А.Т.2, Баймаханов Б.Б.2,1, Сейсембаев М.А.2
1 «С.Ж. Асфендияров атындагы Каза^ ¥лтты^ медицина университет» Ке АК, Алматы Казахстан
2 «А.Н. Сызганов атындагы ¥лттьщ гылыми хирургия орталыгы» АК, Алматы Казахстан
Ацдатпа
Жедел обтурациялык холецистит - eлiм-жiтiм жэне аскыну каут жогары кец таралган ауру. Жанама аурулары бар егде жастагы наукастарта жедел холецистит кезнде, казiргi уакыттагы хирургиялык тактика, ашык жэне лапароскопиялык кол жет 'мдтт айтарлыктай цауп тенд'ред'!. Б'зд'ц зерттеу'ш'зд'ц максаты - жедел обструктивт'1 холецистит кезнде терi бауыр аркылы койылатын холецистостомияныц тиiмдiлiгi жэне одан кей^ лапароскопиялык холецистэктомияны талдау.
Хат алысатын автор. Оспан Ж.Р. - «Жалпы хирургия» мамандыгыныц 2 курс peeuäeHmi, «С.Ж. Асфендияров ат. Каз¥МУ» Ке АК, Алматы Казахстан E-mail: jambyl97@mail.ru
Мудделер цацтыгысы
Аеторлар MYдделер ^а^тыгысыныц жоцтыгын мэлiмдейдi
Туйш сездер:
жедел обтурациялыц холецистит, mepi бауыр арцылы холецистосто-мия, лапароскопиялыц холецистэк-томия, вт тас ауруы
Материалжэне aäicmep. Бiз pempоспeкmивmi mYpдe А.Н. Сызганов атындагы ¥ГХО-да 2017жылдан 2021 жылдар аралыгында жедел обтурациялыц холециститпен емделген 64 науцасты талдадыц, оларды хирургиялыц емдеу квлемне байланысты 2 топца бвлдк. Бipiншi топ науцастарына: бipiншi кезецде ТБХС (N=29), eкiншi кезецде, 3 куннен 72 kyh аралыгында куту мepзiмi вткеннен кейн ЛХЭ жасалды. Екiншi топ науцастарына: вт цабын дренаждамай ЛХЭ жасаган науцастар (N=35). Сондай-ац, бipiншi топтагы науцастар куту уацытына байланысты 3 топшага бвлтШ: А топшасы - ЛХЭ ТБХС орнатылганнан кейн 10 кун шнде орындалды, В топшасы - ЛХЭ ТБХС орнатылганнан кейiH 2 аптадан 4 апта аралыгында орындалды (N=12), С топшасы - ЛХЭ ТБХС - тан кешн 4 аптадан кейн орындалды. Операция алдындагы, операция кезндег деректер жэне операциядан кей^ асцынулар талданды.
Натижелер. Операция алдындагы мэлiмemmep мен дене цызуында, зертханалыц мэлiмemmepдe, цосалцы ауруларда жэне сэйкес epi^e айтарлыцтай айырмашылыц аныцталган жоц. Статистикалыц айырмашылыцтекнауцастардыцжасында аныцталды (65.3±9,0 vs 53,4±15,4). ЛХЭ операция узацтыгы бipiншi топпен салыстырганда, eкiншi топта узагырац болды, б'ращ айтарлыцтай айырмашылыц аныцталмады (108,1 ± 30,5 vs 117,9 ± 39,9). ЛХЭ-дан соц операциядан кей^кезецде 5 (14,2%) жагдайда асцынулар байцалды: 4 (11,4%) жагдайда щан кету жэне 1 (2,8%) жагдайда операциядан кейнгi жараныц ipрцдеуi. Операциядан кей^ жараныц iр'щдеу'не байланысты жара, щайталама кернеумен жазылды. Лапаротомияга конверсия 10 (15,6%) жагдайда жург'з'тд'!, бip (1,5%) жагдайда операция агымында холедохтыц цабыргасы зацымдалды. Сондай-ащ, А, В жэне С топтары арасында айтарлыцтай айырмашылыц аныцталган жощ.
Цорытынды. Осылайша, жедел обструктивт '1 холецистит кезнде ек сатылы емдеуд'1 щолдану (ТБХС, ЛХЭ) ашыц операцияга конверсияны едэу'р азайтады, операциядан кейнгi асцынуды сенмдi турде азайтады жэне операциядан кей^ кезецде твсек-орын кундерн азайтады. Б'!зд'щ зерттеу нэmижeлepiмiзгe сэйкес, ТБХС пен ЛХЭ арасындагы ец оцтайлы аралыц мерзм 4 аптадан астам уацыт.
Эффективность чрескожной чреспеченочной холецистостомии при остром обструктивном холецистите
Автор для корреспонденции: Оспан Ж.Р. - Резидент 2 года обучения по специальности «Общая хирургия», НАО «КазНМУ им. С.Д. Асфендиярова» г. Алматы, Казахстан E-mail: jambyl97@mail.ru
Оспан Ж.Р.1, Досханов М.О.1,2, Сершулы Е.2, Мукажанов Д.Е.2, Хаджиева А.А.1, Тилеуов С.Т.2, Скакбаев А.С.2, Аскеев Б.Т.2, Баймаханов Ж.Б.12, Каниев Ш.А.12, Чорманов А.Т.2, Баймаханов Б.Б.21, Сейсембаев М.А.2
1 НАО «Казахский Национальный медицинский университет им. С.Д. Асфендиярова», г. Алматы, Казахстан
2 АО «Национальный научный центр хирургии им. А.Н. Сызганова», г. Алматы, Казахстан
Конфликт интересов
Авторы заявляют об отсутствии конфликта интересов
Ключевые слова:
Острый обтурационный холецистит, чрескожная чреспеченочная холецистостомия, лапароскопическая холецистэктомия, желчнокаменная болезнь
Аннотация
Острый обтурационный холецистит - распространенное заболевание со значительным риском смертности и осложнений. Активная хирургическая тактика, как открытый и лапароскопический доступ, представляет значительный риск для пациентов пожилого возраста с наличием сопутствующих заболеваний на фоне острого холецистита. Целью нашего исследования является анализ эффективности чрескожной чреспеченочной холецистостомии (ЧЧХС) при остром обтурационном холецистите и последующем лапароскопической холецистэктомии (ЛХЭ).
Материал и методы. Ретроспективно нами было проанализировано 64 пациентов пролеченных с остром обтурационном холециститом в период с 2017 года по 2021 год в ННЦХ им. А.Н. Сызганова, которых мы разделили на 2 группы в зависимости от объема хирургического лечения. Первая группа: пациенты, которым первым этапом установлена ЧЧХС (n=29), вторым этапом, было произведена ЛХЭ в период выжидания от 3 дней до 72 дней. Вторая группа: пациенты, которым была выполнена ЛХЭ без дренирования желчного пузыря (n=35). Также пациенты первой группы разделены на 3 подгруппы в зависимости от время выжидания: группа А - ЛХЭ выполнена в течение 10 дней после установки ЧЧХС, подгруппа В - ЛХЭ выполнена через от 2 недель по 4 недель (n=12), пациентам подгруппы С ЛХЭ выполнена более чем 4 недель после ЧЧХС. Были проанализированы предоперационные, интраоперационные данные и послеоперационные осложнения.
Результаты. По предоперационным данным, значительной разницы в поле, температуре тела, лабораторным данным и сопутствующих заболеваниях не выявлена. Статистическая разница была выявлена только в возрасте пациентов (65.3±9,0 vs 53,4±15,4). Продолжительность операции во
второй группе ЛХЭ было больше по сравнению с первой группой, однако значительной разницы не выявлены (108,1 ± 30,5 ув 117,9 ± 39,9). В послеоперационном периоде после ЛХЭ в 5 (14,2%) случаях наблюдались осложнения: кровотечение 4 (11,4%) случая и нагноение послеоперационной раны в 1 (2,8%) случае. Рана заживала вторичным натяжением в связи с нагноением послеоперационный раны. Конверсия на лапаротомию была произведена в 10 (15,6%) случаях, в одном (1,5%) случае интраоперационно была повреждена стенка холедоха.Также значительной разницы между группами А, В и С, не выявлена.
Вывод. Таким образом при остром обтурационном холецистите применение двухэтапного лечение (ЧЧХС, ЛХЭ) значительно уменьшает конверсию на открытую операцию, достоверно снижает послеоперационное осложнение и меньше койко дней в послеоперационном периоде. Согласно результатами наших исследований, самый оптимальный интервал между ЧЧХС и ЛХЭ является срок более 4 недель.
Relevance
Acute obstructive cholecystitis (AOC) is a common disease with a significant risk of mortality and complications, especially in severe cases of general condition against the background of comorbidities [1]. The "gold standard" for the treatment of this disease is laparoscopic cholecystectomy (LCE) [2]. Traditionally, "open" surgery is reserved for destructive forms of AOC with peritonitis and severe inflammation [3]. Despite the advances made by medical science: ultrasound diagnostics, endosurgical and minimally invasive methods of treating acute cholecystitis still remain the most urgent problem in surgery [4]. According to many authors, about 60% of patients hospitalized in surgical departments for acute cholecystitis will be at high operational risk due to concomitant diseases (cardiovascular disease, chronic lung disease, chronic kidney disease or hypothyroidism, etc.) [5, 6]. Laparoscopic interventions are contraindicated for these patients, due to the fact that this technique involves the use of endotracheal anesthesia, mechanical ventilation, tensioncarboxypneumoperitoneum, the use of electric current for hemostasis and treatment of the gallbladder bed. Elderly patients with subcompensated concomitant pathology are also undesirable "open" cholecystectomy. In this connection, most often in this category of patients, operations draining the gallbladder are used [7]. The essence of gallbladder draining operations is as follows: to level gallbladder hypertension, thereby creating conditions for reducing edema, restoring normal blood circulation in the gallbladder wall, and ultimately stopping an attack of
acute cholecystitis. Currently, in patients with a high operational and anesthetic risk, ultrasound (US) guided percutaneous transhepaticcholecystostomy (PTCS) is most often used, this method has a number of advantages: general anesthesia is not required, speed and ease of implementation, the ability to perform even with complicated forms of acute cholecystitis[8, 9].
According to various studies, PTCS under US, in addition to expectant management, is the only method that prevents serious complications of acute cholecystitis, including empyema, gangrene, perforation or sepsis [10, 11]. It has also recently been suggested that, in some cases, PTCS may provide definitive and safe treatment [12, 13]. For many patients, this serves as a bridge to two-stage surgery [14, 15]. Our work is devoted to a two-stage surgical intervention.
Purpose of study is analysis of the effectiveness of PTCS in AOC and subsequent LCE. Material and methods
We retrospectively analyzed the clinical data of 64 patients treated with AOC during 2017 to 2021 at the A.N. Syzganov National Scientific Center of Surgery. AOC was diagnosed based on complaints, clinical and laboratory-instrumental (full blood count, urinalysis, biochemical blood test, fibrogastroduodenoscopy, US of abdomen) examination. After the diagnosis of AOC was established, the patients underwent PTCS or LCE (Fig. 1). The mean age of all patients was 58.7±13.0 years (23-95). There were 30 men (46.8%) and 34 women (53.2%).
Figure 1.
Study design
Depending on the type of surgical treatment, patients with AOC, were divided into two groups:
1. The first group: patients who underwent PTCS at the first stage (n=29), at the second stage, LCE was performed after 10 days. In this group, the average age was 65.3±9.0 years (43 - 95).
The indication for PTCS was an acute inflamed gallbladder and a high risk of intra- and postoperative complications.
Inclusion Criteria:
- strained gallbladder (according to US)
- the wall of the gallbladder is more than 5 mm. (according to US)
Exclusion Criteria:
- chronic calculouscholecystitis
- ascites (presence of free fluid in the abdomen)
- gallbladder wall less than 5 mm.
According to the timing of the operation, these patients were divided into three subgroups: A, B and C. In patients of subgroup A, LCE was performed
within 10 days (mean 5.3 ± 2.4 days (mean 3-9 days) after PTCS ( n=3), in patients of subgroup B, LCE was performed from 2 weeks to 4 weeks (mean 20.1 ± 3.8 days) after PTCS (n=12), in patients of subgroup C, LCE performed after more than 4 weeks (mean 51.2 ± 13.9 days (29 days - 72 days)) after PTCS (n=14).
In subgroup A, the mean age was 83±8 years. In this group, men accounted for 1 patient (33.3%), women accounted for 2 patients (66.7%). In subgroup
B, the mean age was 63.5 ± 9.7 years (43 years - 85 years). In this subgroup, men accounted for 41.6% (5 patients), women 58.4% (7 patients). In subgroup
C, the mean age was 63 ± 6.5 years (48 years - 77 years). In this group, 6 patients (42.8%) were males and 8 patients (57.2%) were females.
All patients of the first group, PTCS was placed on the first day of hospitalization, due to pain, high feverand according to the US picture of AOC (Figure 2, 3). Subsequently, these patients (45.3%) underwent LCE.
Figure 2.
Puncture and placement of percutaneous transhepatic cholecystostomy under ultrasound guidance
Figure 3.
After insertion of the drain into the gallbladder cavity
The second group: patients who underwent LCE (n=35). The mean age in this group was 53.4 ± 15.4 years. In the second group of 35 patients, there were 16 men (45.7%), 19 women (54.3%).
We divided all patients with AOC into two groups to compare the types of surgical treatment. The clinical results of patients in both groups were analyzed during the follow-up period. We studied the duration
of the operation, complications, conversions and postoperative bed days using data processing in Microsoft Excel, GraphPad.
Results
In our observations in all patients, we obtained the following results:conversion to laparotomy was in 10 (15.6%) cases, in one (1.5%) case, the choledochal wall was injured intraoperatively. Postoperative
complications were observed in 3 (4.6%) cases, postoperative bed-days averaged 5.25 ± 1.2 days.
After PTCS in all patients of the first group, the body temperature returned to normal, pain in the right hypochondrium was stopped.
Control studies showed the subsidence of acute
inflammation, the disappearance of intoxication. On the control US, regression of echographic signs of gallbladder destruction was observed. Subsequently, LCE was performed with a waiting period of 3 days to 72 days, on average 33.6 ± 17.5 days.
Cholecystostomy + LCE LCE P-value
(n=29) (n=35)
mean±st. deviation (min.-max.) mean±st. deviation (min.-max.)
Age 65.3 ± 9.0 (43-95) 53.4 ± 15.4 (23-81) p>0.05
Gender (m/f) (12/17) (16/19) ns
Body temperature 37.2 ± 0.4 (36-39.5) 37.2 ± 0.5 (36.1-38.5) ns
Laboratory data
Bilirubin 25.08 ± 12.9 (93.5 - 4.6) 18.5 ± 9.4 (70.3 - 3.4) ns
Leukocytes 9.3 ± 3.2 (16-3) 9.2 ± 3.3 (19-3) ns
Amylase 42.1 ± 15.7 (112 - 15) 50.5 ± 18.5 (128.9 - 21) ns
Concomitant disease
Respiratory system 2 - ns
The cardiovascular system 16 16 ns
Diabetes mellitus 2 2 ns
Intraoperative and postoperative data
Duration of operations 108.1±30.5 (60-180) 117.9±39.9 (60-320) ns
Conversion 1 9 p<0,05
Complications 0 6 p<0,05
Hospital stay 4.4 ± 0.8 (3 - 10) 6.1 ± 1.6 (2 - 20) p<0,05
Table 1.
Depending on the method of surgical treatment performed -PTCS and LCE, the following improvements were obtained in each group: postoperative hospital stay and conversion
In the first group, the average age was 65.3 years (43-95), the average age in the second group was 53.4 years (23-81). A statistical difference was found. In the first group, patients are comparatively older by 18.3% than patients in the second group (p=0.05).
The duration of the operation in the first group averaged 108.1 min ± 30.5 (60-180 min), the duration of the operation in the second group averaged 117.9 min ± 39.9 (60-320 min). When compared, no statistical difference was found.
The average leukocytes in patients of the first group during hospitalization were 9.3±3.2x10A9/l. (3-16x10A9/l), 3-5 days after cholecystostomy was 6.8±1.6x10A9/l (3-12 x10A9/l)). Similarly, in patients of the second group, the average leukocyte count during hospitalization was 9.2±3.3x10A9/L (3-19x10A9/l), on days 3-5 8.6±1.8x10A9/l (4-17x10A9/l). When compared, no statistical difference was found.
In the first group of patients, at the second stage of treatment, when attempting LCE, in 1 (3.4%) case, conversion to laparotomy was performed due to a massive adhesive process. Comparatively, in the second group, conversion was performed in 9 (25.7%) cases due to an acute inflammatory process. Frequency conversion was higher in patients of the second group by 90% (p=0.05).
In the postoperative period, no increase in body temperature was observed in the first group; in the
second group,21 (60%) patients experienced an increase in temperature up to 38C.
There were no complications during the operation in the first group of patients. In the second group, intraoperative complications were observed in 6 (17.1%) cases. In one (2.8%) case, the choledochal wall was injured intraoperatively, laparoscopic suturing of the choledochal wall was performed with removal of Pikovsky drainage. In the postoperative period, after LCE, in 5 (14.2%) cases, there were complications: bleeding in 4 (11.4%) cases and suppuration of the postoperative wound in 1 (2.8%) case. 4 patients with postoperative bleeding had the intake of hemorrhagic nature of the discharge through the control drainage and a decrease in red blood cells, relaparoscopy was performed, the source of bleeding was the gallbladder bed. Hemostasis was achieved with the help of additional coagulation of bleeding sites, the operation was completed by drainage of the subhepatic space. There was no recurrence of bleeding in any case. When comparing the number of postoperative complications a statistically significant difference was found.
Postoperative hospital stay in the first group averaged 4±0.8 days and in the second group it averaged 6±1.6 days. Statistical difference was found. Postoperative hospital stay in patients of the second group were 38.6% higher than in patients of the first group.
Table 2.
Distribution of patients of the first group according to the terms of the operation: LCE after PTCS
Cholecystostomy + LCE P-value
Group A Within 10 days (n=3) Group B From 14 days to 28 days (n=12) Group C More than 28 days (n=14)
M±m (min.-max.) M±m (min.-max.) M±m (min.-max.)
Conversion 0 1 0 ns
Duration of operation 105 ± 36.6 min (160-65) 109.5 ± 32.0 min (180-60) 113.9 ± 29.4 min (180-60) ns
Complications 0 0 0 ns
Table 3.
Data literature on percutaneous transhepatic cholecystostomy followed by cholecystectomy
Depending on the interval of LCE after PTCS in subgroup B, in 1 (8.3%) case, when attempting LCE, conversion to laparotomy was performed due to massive adhesions. The duration of the operation in subgroup A averaged 105 ± 36.6 min (65-160 min), the duration of the operation in the subgroup averaged 109.5 ± 32.0 min (60-180 min), in subgroup C the average duration of the operation was 113 .9 ± 29.4 min (60-180 min). No complications were observed in all subgroups (Table 2). Discussion
AOC is a common disease with a frequency of 1-3% per year in patients with gallstones (10-20%) [16, 17]. Acute cholecystitis carries a risk of complications, including empyema, gangrene, perforation, and peritonitis. In addition, morbidity and mortality associated with emergency cholecystectomy in critically ill patients: 55-66% and 14-30%, respectively [18].
PTCS is the operation of choice for AOC, in critically ill, aged patients and in patients with concomitant pathologies. The technical success rate of PTCS can be very high in experienced hands, with reported rates of 95-100% [19].
Indications for the use of PTCS for the treatment of acute cholecystitis vary across centers but generally include patients at high surgical risk who have a comorbid condition with severe acute cholecystitis. The latest published guideline "Tokyo Guidelines" mentions moderate acute cholecystitis is also an indication [20,
21], due to a disease duration of more than 72 hours, the latter of which is likely due to severe inflammation and tight adhesions and therefore a higher risk of conversion and cholecystectomy complications [22, 23].
PTCS is performed to decompress the gallbladder in AOC. Consistently, as a result of drainage, a decrease in pain syndrome is observed against the background of regression of the inflammatory process. Comparatively in patients according to statistical data, after surgical treatment, against the background of inflammation of the gallbladder, there are more complications compared to patients who underwent preliminary drainage of the gallbladder [24].
The use of the technique of two-stage treatment of AOC, using US-guided PTCS as the first stage, significantly reduced the incidence of intraoperative and postoperative complications. Most significantly managed to reduce the number of conversion, purulent-inflammatory complications. This pattern finds a quite obvious explanation: in fact, LCE is performed under conditions of subsided inflammation and after appropriate preparation of the patient, i.e. in the so-called "cold" period [8, 9].
Our study shows that in AOC, the use of two-stage treatment (PTCS, LCE) significantly reduces the number of conversions to open surgery, reduces postoperative complications and the number of hospital stay in the postoperative period (p<0.05).
Years Authors Study design Database Comparison Results
2009 Kim et al. [25] Retrospective Single medical center <7 days (n=35) vs 14-39 days (n = 38) In a group < 7 days total hospital stay was shorter
2015 Jung et al. [26] Retrospective Single medical center <10 days (n = 30) vs. >10 days (n = 44) There were no differences between operative time, postoperative hospital stay, conversion to open cholecystectomy, or postoperative complications.
2019 Altieri et al. [27] Retrospective New York State SPARCS Database < 8 weeks (n = 1211) vs > 8 weeks (n=1787) < The 8 weeks group had a higher complication rate and longer stay
SPARCS - A nationwide system for planning and collaborating in research.
The optimal timing of intermittent cholecystectomy remains one of the major concerns in LCE patients with PTCS. Kim's studies looked at the impact of the timing of LCE as a second step after PTCS and not earlier than 14 days, this reduces conversion and complication rates, but increases hospital stay, and patients suffer the inconvenience associated with a cholecystostomy tube [25]. Jung et al. in their studies reported that the most common complication after PTCS was catheter-related (displaced catheter), and therefore it was suggested that LCE was preferable within 10 days after PTCS [26]. Altieri et al.in studies by the patient after PTCS, expected LCE at intervals
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