Percutaneous Cholecystostomy in Acute Cholecystitis: Does Timing Matter?

Optimal Timing of Percutaneous Cholecystostomy across Different Grades of Acute Cholecystitis: A Retrospective Cohort Study

Purpose

Acute cholecystitis (AC) often affects older and critically ill patients. When surgery poses too high a risk, percutaneous cholecystostomy (PC) serves as a bridge to delayed cholecystectomy. But how soon should PC be placed? This study asks whether timing and disease severity influence outcomes. The authors of this study aimed to address the following questions:

• Does earlier PC placement improve patient outcomes?

• Does optimal PC timing vary based on AC severity?

Design

This was a retrospective cohort study performed at a single center in Taiwan. It included all patients who underwent PC for AC between 10/2018–12/2022. AC severity was classified according to the Tokyo Guidelines 2018 (TG18).

TG18 is a clinical framework tool utilized internationally for evaluation and categorization of acute cholecystitis. It aims to standardize the diagnosis and severity grading of acute cholecystitis.

Diagnostic Criteria

• Suspected AC: ≥1 clinical item from A + ≥1 from B.

• Definite AC: ≥1 clinical finding from A + ≥1 from B + ≥1 from C.

A. Local Signs of Inflammation

• Murphy’s sign

• RUQ mass/pain/tenderness

B. Systemic Signs of Inflammation

• Fever

• Elevated CRP

• Elevated WBC

C. Imaging Findings

• Characteristic findings on US, CT, HIDA, and/or MRI/MRCP

Severity Grading (TG18)

• Grade I (Mild): No organ dysfunction, mild local inflammation.

• Grade II (Moderate): No organ dysfunction, but marked inflammation.

  • WBC > 18,000/mm³

  • Palpable, tender RUQ mass

  • Symptoms >72 hours

  • Gangrenous cholecystitis, abscess, biliary peritonitis, emphysematous cholecystitis

• Grade III (Severe): Organ dysfunction present in cardiovascular, neurologic, respiratory, renal, hepatic, or hematologic systems.

Timing Groups by Grade

• Grade I: before vs. after 24 hours

• Grade II: before vs. after 24 hours

• Grade III: before vs. after 6 hours

Primary Outcomes

• Length of stay (LOS)

• ICU duration

• In-hospital mortality

Results

• Grade II: Early PC (<24 hours) reduced LOS (7 vs. 10 days, p=0.0028).

• Grade III: Early PC (<6 hours) reduced LOS (9 vs. 19 days, p=0.010).

• Mortality: No significant difference by PC timing. Outcomes were more influenced by age, comorbidities, and baseline disease severity.

Discussion

• Grade III: Treat like a surgical emergency. Early PC (<6 hours) cut hospitalization in half.

• Grade II: Early PC (<24 hours) improved LOS, but urgency less than Grade III.

• Grade I: No clear benefit from early PC; conservative management remains appropriate.

Limitations

• Retrospective, single-center design → associations, not causation.

• Selection bias: sicker patients may have received earlier PC.

• Limited generalizability: TG18 not widely used in the U.S.; 24/7 IR access not universal.

U.S. Applications

• AC management in the U.S. typically relies on clinical suspicion, imaging, and early surgical consults rather than strict grade-based triage.

• Institutional protocols and physician judgment are central.

• This study highlights the potential value of:

  • Reviewing IR access pathways for critically ill patients.

  • Using Tokyo grading to guide urgency.

  • Encouraging multicenter validation studies in U.S. settings.

Main Takeaways

• Early PC reduces LOS in Grade II and III AC.

• Tokyo Grading provides a practical urgency framework.

• Mortality unaffected by timing; influenced by age, comorbidities, and severity.

• Interventional Radiology is essential in delivering timely, life-saving care for severe AC patients.