E2052. Op or Not? Management of High-Risk Cholecystitis in the 21st Century
  1. Yousuf Qaseem; University of California San Diego
  2. Quinn Meisinger; University of California San Diego
Despite advances in medical care, cholecystitis remains a significant source of morbidity and mortality for many patients. Elderly patients and those with underlying medical disease are at markedly increased risk of perioperative adverse events, with nearly 1 in 3 elderly patients experiencing a post-operative complication. Management of cholecystitis with percutaneous cholecystostomy has proven to be safe and effective for patients who cannot undergo surgery. However, cholecystostomy tubes remain a source of morbidity and decreased quality of life. Many patients are unable to have their cholecystostomy removed due to persistent obstruction of the cystic duct and capping trial failure.

Educational Goals / Teaching Points
We aim to identify patients with high surgical risk, recognize the available non-surgical techniques for the management of cholecystitis, and describe the way in which these procedures are performed.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Many non-surgical treatment options for cholecystitis have been explored over the past several decades. In vitro and in vivo animal studies in the 1990s examined gallbladder ablation with various agents such as ethanol and peroxide, with mixed results. A case study in 2009 demonstrated effective in vivo gallbladder ablation using ethanol in an elderly patient with a malignant biliary obstruction. A recent case series examined gallbladder cryoablation in patients who were not surgical candidates due to medical illness. This series demonstrated a high rate of technical success, although adverse events including severe hemorrhage and recurrent cholecystitis were reported. More recently, a case series showed safety and efficacy of cystic duct embolization and chemical gallbladder ablation in a similar patient population. These patients were treated with an initial procedure involving direct embolization of cystic duct, followed by subsequent instillation of polidocanol into the gallbladder. This series showed a high rate of technical success and a relatively low rate of complications. In effort to prove the safety and efficacy of this technique, we have performed a similar procedure in a single patient with a history of calculous cholecystitis treated with percutaneous cholecystostomy. Cystic duct embolization was performed initially, followed by chemical ablation with first sodium tetradecyl sulfate (STS) and subsequently ethanol and STS. The patient has not yet had success with these ablations, although follow-up is ongoing.

Identifying a safe and effective non-surgical management option for patients with indwelling cholecystostomy tubes following acute cholecystitis remains an important topic. Cystic duct embolization followed by chemical gallbladder ablation is a minimally invasive technique that is both simple and cost-effective. This procedure could potentially be widely adopted as an alternative management strategy for acute cholecystitis, and could reduce the morbidity associated with cholecystostomy tubes and ultimately improve these patients’ quality of life.