practice at our institute is to use percutaneous cholecystostomy in the following scenarios:

Calculous cholecystitis: In patients who are not fit for surgery and not responding to conservative therapy, and those patients who present late (more than a week of symptoms) with severe sepsis or organ dysfunction.

Acalculous cholecystitis: Critically ill patients at high risk for surgery with systemic signs of sepsis..

In our practice, we find it a convenient temporizing maneuver for source control after which the patients can be optimized for elective surgery. For very high risk patients, this can be a definitive treatment.

A review from our institution covering these indications is attached.

regards, raza

Article Emerging indications for percutaneous cholecystostomy for th...

In very sick patients with e. g. heart failure etc or in severly burned patients this is a real alternative to surgery.

Cholecystostomy on my opinion is not a definite solution to a real problem. The inflammed gallbladder is the problem and i believe it should be taken out. I believe anaesthesiology and intensive care nowadays can put up with challanging patients both during and after surgery. My experience has been to remove the causative agent.

It is not possible to make definitive recommendations

regarding treatment by PC or cholecystectomy in elderly or critically ill patients with acute cholecystitis, but pending the results of the CHOCOLATE trial, I think that in acute calculous cholecystitis, percutaneous cholecystostomy can be used like "bridge to surgery", instead the same method in acute acalculous cholecystitis can be considered, on the basis of each patient, a definitive method

I agree that cholecystostomy is a temporising measure in the majority of cases, bridging the gap to definitive surgical or endoscopic treatment.

The point I want to make is that it depends upon the availability of a good on call radiology service also. This may not be available in all cases thus potentially forcing your hand in to surgery.

I agree with Gary on that! Secondly, cholecystostomy is not a common procedure, at least not in hospitals with endoscopic expertise! Hope the CHOCOLATE trial would Provide more guidance

My personal opinion is that cholecystostomy is not a choice in any kind of chlecystitis. Especially in acalculous cholecystitis which the possibility of emphysymatous or gaggrenous cholecystitis is increased cholecystostomy is too risky because of the problematic cystic wall.Personally I performed cholecystostomy in 2 cases.1.A severe shrink cholecystitis in a cirrhotic patient.2.A severe cholecystitis in a Mirizzi 3 syndrome .I n these two cases cholestectomy was dangerous and almost impossible to be done.Symptoms of our patients improved after stones extraction.

Otherwise cholecystectomy must be performed in all cases even as an hemicholecystectomy which is bibliografically acceptable.

I do not agree with Dr George Chatzoulis. Do not consider a priori the technique is not correct until the chocolate trial will be concluded. The possibility that we are going to drain a gangrenous gallbladder is related to an incorrect diagnosis and timing. In this case it is not the cholecystostomy wrong, what is wrong is the diagnosis and the indication to the technique. It is true that the diagnosis of gangrenous cholecystitis is not easy, you must have a high level of suspicion of this complication before you have signs of gas development in the context of the gallbladder wall. I think so.

Based upon all I have read and my personal experience, cholecystectomy should be the goal in the treatment of cholecystitis. At my institution, percutaneous cholecystostomy is performed only as a bridge to definitive treatment in the too sick patient to undergo surgery and / or when the medical treatment fails.

We do consider acalculous cholecystitis in a different way: the risk of evolution to a sepsis situation is too high, even in the absence of signs of parietal or intraluminal gas at the start; as so, we tend to always operate on these patients, an attitude that has been much more successful than trying to deal with this condition by placing a percutaneous cholecystectomy - our experience has been dismal...

In all cases, when the slightest suspicion of empyema or emphysema arises, we do operate.

Obviously, despite these general statements, we do have to individualize the therapeutic strategy.

excellent discussion.In a series of 30,000 Lap chole's, i was forced to request for PC

in 5 patients.These patients were sick,elderly with multiple comorbities.Most of them were admitted in the mid night.In one the PC was not effective.However PC has a role to buy time to stabilize and perform a safe lap chole.

I agree that laparoscopic cholecystectomy is the gold standard for the treatment of acute cholecystitis. However, this treatment modality is asscociated with high mortality in critically ill patient with multiple medical comorbidities. Majority of patients with acalcular cholecystitis are eldelry, with multi-organ impairment and are critically ill in the intensive care unit. In such situation, percutaneous cholecystostomy and intravenous broad-spectrum antibiotics is the treatment of choice. The tube is usually removed after 6-8 weeks. This method is used as a 'bridge' to surgery when the patient's condition is more optimal and this will minimize the rate of morbidity and mortality.

I totally agree that LC should be offered to all comers with acute cholecystitis if they are fit for anaesthesia

I agree that there is a role for percutaneous cholecystostomy. The gold standard remains laparoscopic cholecystectomy, but for patients who are critically ill i.e. severe sepsis/shock, then cholecystostomy may act as a bridge to allow stabilisation and subsequent cholecystectomy if required.