Optimal Timing of Percutaneous Transhepatic Gallbladder Drainage in High-Risk Acute Cholecystitis Patients and Its Impact on Elective Laparoscopic Cholecystectomy

Introduction

Acute cholecystitis, a prevalent cause of abdominal pain, manifests in calculous and acalculous forms, constituting 90% of cases. Severity, as classified by Tokyo Guidelines 2018, ranges from mild to severe based on multiple factors.¹ The gold standard treatment, laparoscopic cholecystectomy (LC), is ideally performed within 72 hours for mild to moderate cases.² However, for patients at high surgical risk, such as the elderly or critically ill, percutaneous transhepatic gallbladder drainage (PTGBD) serves as a less invasive option. PTGBD, introduced by Radder et al., in 1982, is proven to be safe and effective, often acting as a precursor to elective cholecystectomy. Nonetheless, determining the optimal timing for PTGBD remains contentious, as early intervention may halt disease progression, while delayed intervention risks exacerbating complications.³ Our study, conducted at Xinjiang Medical University from January 2017 to June 2022, scrutinized high-risk patients who underwent PTGBD followed by elective cholecystectomy, shedding light on its influence on complications, surgical complexity, and pathological outcomes.

Materials and Methods

The data were collected from the First Affiliated Hospital of Xinjiang Medical University between 2017 and 2022. The following case involves a patient who was admitted to the hospital while on a trip to Japan. He presented with acute cholecystitis and was classified as high risk. Consequently, he could not undergo laparoscopic cholecystectomy (LC) and instead chose PTGBD treatment. This study encompasses the clinical data of 66 patients who underwent cholecystectomy at different intervals following their surgeries.

Inclusion criteria

According to the Tokyo Guidelines 2018, patients are diagnosed and classified for severity in acute cholecystitis as follows: Patients with mild or moderate acute cholecystitis, characterized by a Charlson Comorbidity Index (CCI) of ≥6 or an American Society of Anaesthesiologists (ASA) score of ≥3; Patients with severe acute cholecystitis with a CCI of ≥4 or ASA of ≥3, or presenting with jaundice, neurological, or respiratory dysfunction; Following PTGBD treatment, patients should have undergone cholecystectomy no sooner than six weeks after the procedure.

Exclusion criteria

Patients who underwent PTGBD for obstructive jaundice or other biliary tract diseases caused by malignant tumour invasion; cases with a history of upper abdominal surgery or coagulation dysfunction; PTGBD performed as a treatment for end-stage disease; cases with incomplete clinical data were excluded from the study.

Research method

This study utilized a retrospective case analysis, reviewing clinical data alongside current research to evaluate the timing of PTGBD in acute cholecystitis. Cases were categorized into "early intervention" and "late intervention" groups based on the time from symptom onset to PTGBD. The study investigated procedure-related complications, difficulty in elective gallbladder resection, and its impact on pathology results, providing insights into the clinical efficacy of PTGBD placement in high-risk patients.

Operation methods

PTGBD was performed using the Seldinger puncture technique under ultrasound guidance.

1.  The Colour Doppler ultrasound was used to scan the gallbladder area. Generally, the 7th and 8th intercostal spaces on right anterior axillary line are selected for needle insertion. The needle position, direction and depth were determined under ultrasound.

2.   Routine disinfection of the puncture area was performed.

3.   About 5 to 10 mL of 2% lidocaine was applied to the skin at the puncture point for local anaesthesia.

4.  The needle was punctured under ultrasound guidance till it entered the gallbladder and the bile flow was noted. The guide wire was inserted and the puncture needle was withdrawn.

5.   A skin expander was used to expand the skin and intercostal muscles, and inserted along the guide wire.

6.  Following this, the guide wire was pulled out, position of the drainage tube was determined through ultrasound, and confirmed if the tail end of the catheter was in the gallbladder.

7.  A 3-0 silk thread was used to fix the drainage tube to the skin, and a sterile dressing was applied to the puncture site.

8.  The bile was extracted and stored in a sterile container and sent to the laboratory for microbial culture.

9.  The distal end of the catheter was connected to a drainage bag and left in place to facilitate drainage.

Collection of information

The data were collected from The First Affiliated Hospital of Xinjiang Medical University between 2017 and 2022 from the patients admitted for acute cholecystitis who underwent elective cholecystectomy after the first PTGBD treatment following admission. A total of 66 patients, including 39 males and 27 females were recruited. The median time was two days (0-8 days) and the clinical operability was practical. The early intervention group (≤2 days, n=30) and the late intervention group (>2 days, n=36) were defined.

Early intervention group: 15 males and 15 females; aged 36-87 years, average age of 71.1±10.2 years; included 18 cases of hypertension, 16 cases of diabetes. There were 14 cases of coronary heart disease, four cases of chronic obstructive pulmonary disease, and seven cases of chronic renal failure.

Late intervention group: 21 were males and 12 were females; aged 50-87 years, with an average age of 72.1±7.2 years. There were 23 cases of hypertension, 18 cases of diabetes, 19 cases of coronary heart disease, three cases of chronic obstructive pulmonary disease, and 10 cases of renal failure.

No statistical difference in the general data between the two groups (P >0.05) was noted. The collected information included, gender, age, comorbidities, disease onset time, PTGBD time, LC time, reasons for catheterization, complications related to catheterization, surgical blood loss, operation time, degree of adhesion, conversion rate, postoperative gallbladder pathology results.

Quality control

In hospitals, PTGBD and cholecystectomy were performed by doctors with professional titles of attending physician and deputy chief physician or above, respectively, and their operating experiences were comparable. While evaluating the difficulty of surgery, only the degree of adhesion was considered as a subjective indicator. Since there is no quantitative method for assessing adhesions, in order to reduce its subjective impact to the utmost, the surgical records described tight tissue adhesions in the anatomical part of the gallbladder triangle and its surroundings or the difficulty in complete removal of gallbladder due to gallbladder oedema as ‘severe adhesions’, while others were defined as ‘mild adhesions’. Severe adhesions in the gallbladder triangle, pronounced gallbladder oedema, or abnormal anatomical positioning necessitated the conversion of laparoscopic cholecystectomy to open cholecystectomy. Gallbladder pathology was classified based on the Tokyo Guidelines 2013 as follows: stage I (oedematous cholecystitis, 2-4 days), stage II (necrotizing cholecystitis, 3-5 days), stage III (suppurative cholecystitis, 7-10 days) and chronic cholecystitis.

Statistical methods

All data were processed using SPSS 26.0 statistical software. For data description, the frequency of counting data was used, and the median and interquartile range were used for measurement data. For data analysis, the Chi-square test was used for comparison between numerical data groups, and the non-parametric test for two independent samples was used for measurement data. P <0.05 was considered statistically significant. The correlation between variables was evaluated using the Spearman correlation coefficient test.

Results

Basic information of patients

All 66 patients who met the inclusion and exclusion criteria, from acute cholecystitis symptoms to PTGBD were included. The average time interval was 3.4±2.5 days, and the median time was two days (range: 0-8 days). Patients were divided into two groups based on the median time and clinical feasibility (early intervention group: ≤2 days, n=30; late intervention group >2 days, n=36). The median time from the onset of acute cholecystitis symptoms to PTGBD was one day in the early intervention group and six days in the late intervention group. The patient severity criteria based on 2018 Tokyo guidelines for the classification of acute cholecystitis severity is as follows:

Grade III (severe) acute cholecystitis

Acute cholecystitis with >1 of the following organ dysfunction

1.   Cardiovascular dysfunction: Hypotension requires dopamine 5 μg/(kg/min) or the use of norepinephrine adenosine

2.  Nervous system dysfunction: consciousness disorder

3.   Respiratory dysfunction: PaO₂/FiO₂<300

4.  Renal dysfunction: oliguria, serum creatinine >176.8 μmol/L

5.  Hepatic insufficiency: PT-INR>1.5

6.   Hematopoietic dysfunction: platelets <100×109/L

Grade II (moderate) acute cholecystitis

Acute cholecystitis combined with two of the following.

1.  White blood cell count>18×109/L

2.  A tender mass in the right upper quadrant

3.   Time of onset >72 hours

4.   Obvious local inflammation (gangrenous cholecystitis, pericholecystic abscess, bile peritonitis, emphysematous gallbladder

 Grade I (mild) acute cholecystitis

Acute cholecystitis does not meet the diagnostic criteria of Grade II or Grade III

The basic clinical data of acute cholecystitis severity is listed in Table 1. There were no statistically significant differences in the parameters of age, gender, and comorbidities between the two groups. There was no significant difference in the basic clinical characteristics between the two groups, demonstrating that the patients in the two groups were comparable.

Table 2 shows that, compared with the late group, more patients in the early group underwent PTGBD due to sepsis (40% vs 16.7%, P=0.034). In the late-stage group, PTGBD was performed due to persistent fever in more patients (0% vs 19.4%, P=0.013).

Table 3 shows that both groups experienced compli-cations related to PTGBD, such as catheter detachment. There was no significant difference between the groups in complications such as abortion, bleeding, bile fistula, and infection (P>0.05). Additionally, there were no procedure-related deaths.

Table 4 shows that when the time interval from the onset of symptoms related to acute cholecystitis to PTGBD was ≤2 days (early group), several outcomes were improved. The operation time was significantly shortened (117.5 min, 105.8-126.5 min) vs (133.0 min, 120.0- 148.0 min), P=0.001; intraoperative blood loss was less (20.0 mL, 8.0-44.3 mL) vs (40.0 mL, 16.3-95.0 mL), P=0.017; the rate of severe adhesion was significantly reduced (5/30 [16.7%] vs 20/36 [55.6%], P=0.001), and the rate of conversion to laparotomy was significantly lower (3/30 [10%] vs 11/36 [30.6%], P=0.042). Through Spearman correlation coefficient analysis, a correlation was observed between the interval time from symptom onset to PTGBD and the surgical conversion rate (Rs=0.25, P=0.043).

Pathological results

According to the pathological results, Table 5 shows that severe adhesion rate in the chronic cholecystitis group was significantly lower (3/33 [9.1%]vs 22/33 [66.7%], P<0.001) compared with other groups. Moreover, the proportion of cases with an interval of ≤2 days from the onset of acute cholecystitis symptoms to PTGBD was significantly higher in chronic cholecystitis group compared to other groups (21/33 [63.6%] vs 9/33 [27.3%], P=0.003).

PTGBD indications

PTGBD can be used for bladder decompression under local anaesthesia in cases of cystic duct obstruction, requiring relatively high clinical conditions for the patient. Gallbladder decompression can reduce the inflammatory process, alleviate the patient's clinical symptoms, and help facilitate recovery from related failing systems, providing a bridge for definitive treatment of delayed cholecystectomy. Some studies have shown that in patients with calculus-related acute cholecystitis requiring PTGBD, the severity of acute cholecystitis was not the primary indication for catheterization. Instead, the patient's comorbidities, which increase the risks associated with anaesthesia and surgery, were the main consideration. Additionally, some studies did not clearly define the criteria, but only broadly recommended that PTGBD should be used for patients at high surgical risk. Boules and his colleagues conducted a retrospective analysis involving 424 patients who underwent PTGBD in 2016.⁴ Physicians determined whether a patient was high-risk for surgery, and the data analysis identified five risk factors for PTGBD placement: heart surgery within two months of symptom onset, lung infection, newly diagnosed pulmonary embolism, end-stage liver disease with cirrhosis, use of systemic anticoagulants, and hemodynamic instability. Additionally, some of their retrospective studies have suggested other indications, such as stage IV advanced cancer and coronary atherosclerotic heart disease.⁵

An early retrospective study analyzed patients admitted to the hospital with severe cholecystitis and those undergoing PTGBD. Researchers classified the severity of the disease based on the patient's systemic inflammatory response syndrome (SIRS) classification, combined with radiological imaging findings (gallbladder gas production, gallbladder perforation). More than 50% of the patients in the study had cardiovascular disease or underlying malignancies, and they were considered high-risk for surgery.⁶

The TG18 guidelines define this group as high risk for early surgical intervention. According to TG18, for patients with mild to moderate acute cholecystitis:¹

• If the patient’s Charlson Complication Index (CCI) score is greater than or equal to 6 points, or the American Society of Anaesthesiologists (ASA) grade is high, PTGBD is recommended when inflammation (at or equal to three points) is not controlled by antibiotics and supportive care.

• PTGBD is also recommended for patients with jaundice, neurologic or respiratory dysfunction, or related organ system dysfunction that cannot be rapidly reversed with treatment.

• For patients in whom antibiotics and supportive sex therapy are effective, and cardiovascular or renal organ system failure is reversed, but their overall performance status remains poor.

• It is also recommended for patients with severe acute cholecystitis (CCI score ≥ 4 points, ASA grade ≥ 3).

• In acalculous acute cholecystitis, primarily occurring in critically ill patients due to obstruction, PTGBD is a common intervention.

This prospective study, part of a large review on acute cholecystitis, analysed 704 patients who underwent PTGBD and compared their outcomes with those undergoing cholecystectomy. The findings revealed lower morbidity, but similar mortality rates with PTGBD. Based on these results, the investigators recommend considering PTGBD insertion as a definitive treatment or opting for cholecystectomy in patients with acalculous cholecystitis, considering the increased risk of conversion to laparotomy and associated morbidity. Mortality rates remain elevated following PTGBD for patients with acalculous acute cholecystitis, with 30- day and in-hospital rates ranging from 9% to 21%. Despite these figures indicating PTGBD's limitation as a definitive treatment for patients who are able to tolerate cholecystectomy, approximately one in ten patients ultimately undergo cholecystectomy as the final treatment.

PTGBD technology

PTGBD is typically performed under radiographic guidance, with color Doppler ultrasound being the preferred modality due to its widespread availability and real-time imaging capability. Alternatively, stable patients may undergo CT-guided surgery, which offers excellent spatial resolution, although it is more cumbersome. CT-guided interventional therapy is often reserved for cases where the gallbladder is not visualized by ultrasound due to anatomical or pathological reasons. Two puncture techniques are generally employed: the Seldinger technique via the transhepatic approach and Trocar technology through the transabdominal route. In our hospital, the Seldinger technique is predominantly utilized for puncture, as it offers reliable outcomes and the same was employed in all patients in this study.

The effectiveness of PTGBD

The American Society of Interventional Radiology defines the successful treatment (efficacy) of PTGBD for acute cholecystitis as achieving fever reduction, pain symptom relief, and decreased inflammatory markers.⁷ A systematic review reported a success rate of 85.6% in patients with typical acute cholecystitis treated with PTGBD.⁸ However, this rate may be lower in patients with multiple comorbidities or hemodynamic instability. A randomized clinical trial demonstrated that PTGBD leads to rapid resolution of clinical symptoms, including sepsis, in high-risk surgical patients, outperforming late-stage laparoscopic cholecystectomy (LC) after conservative treatment.⁹ Nevertheless, the impact of LC after PTGBD remains unaddressed in our research scope. Currently, no randomized clinical trials attempted to compare PTGBD with LC in patients without serious comorbidities, making such comparisons meaningless as PTGBD is typically reserved for patients with severe comorbidities. Early LC is recommended as an alternative when LC is intolerable, provided the patient is assessed as fit for surgery.

LC is widely regarded as the definitive treatment for cholecystitis; however, the role of PTGBD complicates this view. Cholecystitis patients are classified into calculus and acalculous types based on the presence of stones. While some PTGBD studies focus on acute cholecystitis broadly, few differentiate between these types. Scholars argue over the relevance of this distinction, with concerns about potential bias. Nevertheless, research indicates PTGBD as an effective option for acalculous acute cholecystitis patients unsuitable for primary cholecystectomy. Despite its higher complication rates, PTGBD offers a viable treatment alternative, often resulting in successful outcomes and subsequent reduced cholecystectomy rates. Overall, PTGBD proves to be successful as a final treatment in most acalculous acute cholecystitis cases, with low mortality and subsequent cholecystectomy rates.^10,11

Among patients with acalculous acute cholecystitis, studies indicate that those treated with PTGBD or antibiotics alone (non-surgical group), exhibit a recurrence rate of cholecystitis at 9.8%. While the PTGBD subgroup within the non-surgical group showed a slightly higher relapse rate compared to the antibiotic-only subgroup, the difference was not statistically significant. Speculation suggests that once gallbladder inflammation improves in acalculous acute cholecystitis patients treated with PTGBD, normal gallbladder function is restored, potentially impacting recurrence rates.¹¹

PTGBD timing of intervention

The timing of surgery for acute cholecystitis holds significant clinical importance, as improper timing of endoscopic cholecystectomy may lead to a higher conversion rate to laparotomy, prolonged hospitalization, and related complications. Despite years of clinical demonstration, PTGBD remains effective in high-risk surgical patients. It is considered a safe and effective alternative that can assist such patients during elective abdominal surgery, with maximum benefit achieved from laparoscopic cholecystectomy. Key questions regarding the timing of PTGBD intervention include the following three situations.

PTGBD and traditional conservative treatment

In a 2002 randomized clinical trial conducted by Hatzidakis, acute PTGBD was compared with conservative treatment in high-risk cholecystitis patients unsuitable for surgery. The results showed that PTGBD is a suitable treatment option if there is no response to medical treatment after three days, with 87% of patients experiencing symptom resolution after the third day.¹² Follow-up studies suggest that symptomatic treatment with antibiotics, drainage, or analgesics is feasible for cholecystitis. However, due to the frequent recurrence of the original condition, PTGBD should be viewed as a bridge to surgery, rather than a final solution. In some cases, despite conservative treatment, progression of the underlying disease may necessitate emergency surgery, though this is not aligned with typical clinical practice.¹³ Generally, PTGBD is reserved for critically ill acute cholecystitis patients who fail to respond to antibiotics, indicating a method used only when initial treatment proves ineffective.

Timing of cholecystectomy after PTGBD

What is the optimal interval between LC following PTGBD surgery to achieve conversion rates, minimize complications, and reduce hospitalization? Determining the timing of this transition remains uncertain. The timing of subsequent LC after PTGBD remains controversial, with a hypothesis suggesting that early surgical intervention may lead to less fibrotic and inflammatory changes, facilitating careful dissection of the complex anatomy of the gallbladder trigone. However, early surgery, as observed in some studies, may lead to increased intraoperative blood loss, longer duration, and higher complication rates compared to delayed surgery.¹⁴

PTGBD catheter management

International clinical approaches vary slightly for patients with different types of acute cholecystitis. Typically, two weeks after PTGBD catheter placement, repeat cholangiography is performed to assess stone presence, cystic duct patency, and catheter location. For patients with calculus cholecystitis who are candidates for surgery, cholecystectomy is usually recommended. If surgery is not an option, percutaneous cholecystoscopic stone removal is performed 6-8 weeks after initial catheter placement. If a patient with acute cholecystitis shows no clinical symptoms and the cystic duct is patent with clear cholangiogram findings, the PTGBD catheter is clamped 6-8 weeks after initial placement to achieve intra-gallbladder drainage. If the patient tolerates the clamping test without bile duct obstruction or intra-abdominal contrast medium leakage, the catheter can be removed 1-2 weeks after clamping. In this study, all the patients were reviewed and evaluated for laparoscopic cholecystectomy after six weeks.

PTGBD should be reserved for patients who do not respond to antibiotics and supportive care, particularly when underlying comorbidities or acute illness preclude cholecystectomy. The severity of gallbladder inflammation or duration of symptoms alone are not absolute contraindications to cholecystectomy or PTGBD. Patients may not tolerate surgery due to severe systemic diseases like cardiovascular conditions, underlying malignancy, or conditions incompatible with general anesthesia. For Grade III acute cholecystitis, if patients respond well to antibiotics and supportive care, they may be transferred to a hospital with appropriate surgical expertise, anesthesia, and ICU support for re-evaluation for possible cholecystectomy. As with any intervention, there are risks and benefits to consider, and physicians must weigh them carefully alongside the long-term consequences. Following PTGBD placement, patients' clinical status should be closely monitored, and once the acute episode resolves, efforts should focus on optimizing their underlying medical condition and performing cholecystectomy if feasible.

 The influence of PTGBD on gallbladder pathology outcomes

In our surgical records, we assessed adhesion severity and strategize intraoperative approaches accordingly. Although the factors affecting conversion rates due to surgical anatomy remain unclear, we have observed that as the time interval between PTGBD and symptom onset increases, the surgical difficulty rises, particularly evident in cases with noticeable adhesions. This trend mirrors the impact of post-PTGBD interval on septal LC. While the YAMADA study indicates that PTGBD does not affect pathological findings, the interval between acute cholecystitis onset and PTGBD does influence surgical duration. According to a recent study by Takashi Sakamoto et al., mortality or morbidity rates appear to be optimized with cholecystectomy performed within 7 to 26 days post-PTGBD, as suggested by RCS curves analyzing this interval. Early surgery may lead to acute inflammation, compromising the surgical field and increasing the risk of injury to other organs and tissues. Conversely, delaying surgery may lead to fibrosis of the gallbladder and surrounding tissues, complicating surgical resection.¹⁵

We believe that the time intervals from symptom onset to PTGBD and from PTGBD to LC play a crucial role in preventing the acute progression of gallbladder inflammation and the spread of inflammation to surrounding tissues. However, clinicians often cannot control the time from symptom onset to hospitalization. Therefore, upon admission of patients with acute cholecystitis, clinicians should promptly decide on the treatment approach based on the severity of the patient's condition. If early LC is deemed unfeasible, PTGBD should be considered as soon as possible. This approach can help reduce the surgical complexity in cases of delayed acute cholecystitis. Additionally, studies have shown that while PTGBD effectively addresses acute symptoms, it may lead to severe fibrosis between the gallbladder and surrounding liver tissues in many patients.¹⁶ The increasing difficulty of cholecystectomy after PTGBD, especially within the 7-26 day range, may be attributed to the severe fibrosis caused by PTGBD during the gallbladder healing process. This fibrosis ultimately makes LC more challenging. However, further research is needed to conclusively establish whether PTGBD exacerbates the surgical difficulty of LC. While PTGBD offers benefits for high-risk patients, the decision to utilize it requires careful consideration and individualized evaluation.

A cohort study of patients with severe acute cholecystitis revealed that those undergoing gallbladder drainage with PTGBD had poorer short and long-term outcomes compared to those without it. Specifically, patients with catheters experienced higher readmission and mortality rates, lower likelihood of undergoing cholecystec-tomy within two years of hospitalization, longer hospitalization times, and increased complications.¹⁷ Moreover, a recent Dutch study targeting patients with APACHE II scores >7 had to be abandoned due to significantly higher rates of reintervention and incidence.¹⁸ These conflicting findings underscore the necessity for more precise indications and specific research in this area.

Discussion

The incidence of gallbladder stones in adults is between 10% and 15%, and it is one of the most common gastrointestinal diseases.¹⁹ International data show that approximately 80% of gallbladder stones exist in asymptomatic form. Cystoliths can block the top of the impacted cystic duct, causing cholestasis, which can lead to gallbladder enlargement, biliary strangulation and pain. Repeated, long-term obstruction can lead to inflammation, infection, and even ischemic necrosis, a common condition called acute cholecystitis. Among patients with symptomatic gallstones, 10% may develop acute cholecystitis.²⁰ In patients younger than 50 years, the likelihood of developing acute cholecystitis in women is three times more than that of men.²¹ Recurrent acute cholecystitis may develop into chronic gallbladder disease after non-surgical treatment. The gallbladder of these patients is characterized by thickening of the gallbladder wall, atrophy and fibrosis of the gallbladder mucosa.²² Accurate diagnosis of acute cholecystitis requires a multifactorial, systematic approach, including detailed disease history, physical examination, laboratory tests, and imaging tests. After years of development, the Tokyo guidelines (TG07), introduced in 2007, provided a complete set of diagnostic criteria and a severity grading table for cholecystitis. A subsequent series of studies showed the sensitivity and specificity of the TG07 guidelines as 85% and 50%, respectively.²³ According to the diagnostic criteria, in the 2013 Tokyo Guidelines (TG13), the sensitivity and specificity were increased to 91% and 97%, respectively.²⁴ A review of 216 relevant articles since the inception of TG13, including 19 randomized controlled trials, demonstrated that the severity classification accurately predicts mortality, length of hospital stays and conversion rate to laparoscopic cholecystectomy.^25,26 The description of Tokyo Guide 2018 (TG18) is mentioned in Table 1. For patients with severe (Grade III) acute cholecystitis, the 2013 Tokyo Guidelines initially recommended only the use PTGBD, antibiotics, and delayed cholecystectomy. A 2010 retrospective study compared patients with severe acute cholecystitis who received PTGBD versus those who did not. The results showed that the PTGBD group had higher 30-day, 90-day, and two-year mortality and readmissions. The elderly patients with severe acute cholecystitis were more likely to undergo cholecystectomy within two years after admission.²⁷ Considering these findings, the authors suggested strict adherence to the Tokyo guidelines for proper evaluation and better outcomes. Since then, the "Tokyo Guidelines 2018" have been revised, recommending that institutions with advanced conditions and experienced surgeons use early laparoscopic cholecystectomy to treat patients with severe acute cholecystitis effectively. However, in severe acute cholecystitis or high-risk patients, the mortality rate of laparoscopic cholecystectomy ranges from 5% to 30%.²⁸ After surgery, the incidence of complications such as biliary injury and biliary fistula is high.²⁹ Therefore, for patients with severe acute cholecystitis or those at high-risk surgical risk, PTGBD technology was developed to address acute symptoms, delay or even reverse the progression of local and systemic complications, and provide a safer alternative. The advantage of PTGBD is that it does not require general anesthesia, can be performed at the bedside, is simple and fast, has a catheterization success rate of more than 95%, and the incidence of complications is quite low. The mortality rate of surgical procedures in high-risk patients was later reduced to 10%-12%.

This study was limited by the moderate sample size. A very large sample size would have made the study stronger.

Conclusion

This study analyzed patients undergoing percutaneous transhepatic gallbladder drainage (PTGBD) based on their median PTGBD time and clinical operability. On comparing the two groups, there were no significant differences in demographics at the time of admission, in complications, or  catheterization phases. However, early PTGBD intervention (≤2 days) post-symptom onset was associated with reduced surgery time, intraoperative blood loss, conversion rates, and pathological progression of gallbladder inflammation. Early PTGBD may decrease the likelihood of conversion to laparoscopic cholecystectomy in acute cholecystitis patients.

Ethical Approval

The decision was taken by the Clinical Research Ethics Committee of the first Affiliated Hospital of Xinjiang Medical University on the date of 01.08.2022 and the number XJMU-4-65-00005.

Competing Interest

The authors declare that they have no competing interests.

Funding

None