Impact of Percutaneous Transhepatic Gallbladder Drainage on The outcome of Laparoscopic Cholecystectomy

Tomoyuki Nagata, Yuen Nakase, Kei Nakamura, Satoshi Mochiduki, Mitsuhiro Fujino, Shozo Kitai, Seishiro Inaba

Tomoyuki Nagata, Yuen Nakase, Kei Nakamura, Satoshi Mochiduki, Mitsuhiro Fujino, Shozo Kitai, Seishiro Inaba, Department of Surgery, NaraCity Hospital, Nara, Japan

Correspondence to: Tomoyuki Nagata, Ph.D, Department of Surgery, NaraCityHospital 1-50-1 Higashikidera-cho, Nara-city, Nara 630-8305, Japan.
Email: drgechum@koto.kpu-m.ac.jp
Telephone: +81-0742-24-1251
Fax: +81-0742-22-2478
Received: November 5, 2015
Revised: December 20, 2015
Accepted: December 23, 2015
Published online: January 13, 2016


AIM: The recommended treatment for acute cholecystitis is early laparoscopic cholecystectomy (LC) within 72 hours after onset of symptoms. However, palliative treatment using percutaneous transhepatic gallbladder drainage (PTGBD) is often chosen for clinical and logistical reasons, including difficulty performing early surgery due to manpower constraints.The goal of this study was to investigate the clinical significance of PTGBD on the outcome of patients with cholecystitis in our hospital.

MATERIALS AND METHODS: Relationships between preoperative drainage status (treatment with or without PTGBD) and clinicopathologic factors were examined in 190 patients withcholecystitis who underwent LC.The short-term impact of preoperative drainage on prognosis was evaluated by univariate and multivariate analysis.

RESULTS: Preoperative PTGBD was performed in 24 patients (12.6%).The average period between PTGBD and LC was 21.0 days. Preoperative PTGBD had a significant correlation with operation time and length of stay (LOS) after surgery (p<0.0001). In patients aged ≥65, preoperative PTGBD was found to be a significant short-term prognostic factor in univariate analysis (LOS: 10.43 vs. 5.39days, p<0.0001) and multivariate analysis (p=0.0488).

CONCLUSIONS: Preoperative PTGBDiscorrelated with an extended hospital stay after surgery and is an independent short-term prognostic factor in cholecystitis patients aged ≥65 years old.

© 2016 ACT. All rights reserved.

Key words:Cholecystitis; Hospital Stay; Laparoscopic Cholecystectomy; Percutaneous Transhepatic Gallbladder Drainage (PTGBD)

Nagata T, Nakase Y, Nakamura K, Mochiduki S, Fujino M, Kitai S, Inaba S. Impact of Percutaneous Transhepatic Gallbladder Drainage on The outcome of Laparoscopic Cholecystectomy. Journal of Gastroenterology and Hepatology Research 2016; 5(1): 1899-1902 Available from: URL: http://www.ghrnet.org/index.php/joghr/article/view/1460


The recommended treatment for acute cholecystitis is early laparoscopic cholecystectomy (LC) within 72 hours after onset of symptoms.However, conservative treatment using percutaneous transhepatic gallbladder drainage (PTGBD)is often chosen for clinical reasons or due to difficultyarranging an early operation because of manpower constraints. Previous studies have advocated early surgery for patients with cholecystitis because of the poor course after delayed surgery. However, an early operation may also be a contributory factor in conversion to laparotomy, and it is important that an appropriate quality of laparoscopic surgery is maintained[1,2].

This study was designed to investigate the short-term prognostic significance of PTGBD in patients with cholecystitis who underwent LC in our hospital. Relationships between the preoperative drainage status and other clinicopathologic factors were also evaluated.


A total of 224 patients with cholecystitis underwent cholecystectomy at NaraCityHospital from April 2012 to October 2014. Cholecystitis was defined as a case with imaging findings on CT or US of gallbladder wall thickening or biliary sludge or abnormal findings in surrounding tissues,and any one of (i) right hypochondrium, epigastric pain/tenderness, or presence of a Murphy sign, (ii) body temperature ≥37°C, or(iii) leukocytosis and elevated CRP. Clinicopathologic findings were obtained retrospectively from hospital records. Thirteen patients diagnosed with gallbladder cancer or gallbladder polyp and 21 who underwent surgery while still asymptomatic were excluded from the study.

Of the remaining 190 patients, 24 first received PTGBD as conservative treatment and then underwent LC after reduction of inflammation. The other 166 patients underwent LC without PTGBD and were used as a control group. Relationships between drainage status (that is,useof PTGBD) and other clinicopathologic factors were examined, and the prognostic impact of PTGBDwas evaluated by univariate and multivariate analysis. Length of stay (LOS) after surgery was used as an index of short-term prognosis.The 190 patients were also divided into subgroups according to age to investigate the relationship between clinicopathologic factors and short-term prognosis of patients aged ≥65 years old.

Statistical analysis and graphing were performed with JMP 7.0.1 (SAS Institute Inc., Tokyo). Continuous data are expressed as the median or mean, depending on the data distributions. A chi-square test and t-test (or Fisher test) were used for univariate comparisons. Differences in LOS were compared by a Wilcoxon test, using the date of LC as the starting point. Multivariate analysis of prognostic factors related to LOS was performed using a Cox proportional hazard model with variables that were significant prognostic factors in univariate Wilcoxon analysis. P<0.05 was considered to indicate significance in all analyses.


PTGBD was performed for 24 patients (12.6%) with cholecystitis as conservative treatment to control inflammation before LC. The mean period from PTGBD to surgery was 21.0 days. The clinicopathologic features in the PTGBD and control groups are listed in Table 1. There were significant differences in age,diabetes as a comorbidity, operation time, blood loss, complications and LOS after surgery (p<0.05), but not in the rate of conversion to laparotomy or degree of inflammation.

Five of the 24 patients who underwent PTGBD developed complications, but no cases had organ or space surgical site infection (SSI). The complications were intraoperative bile duct injury in 1 patient, postoperative bile spillage in 1 patient, and incisional SSI in 3 patients. The rate of incisional SSI was significantly higher in the PTGBD group (12.5% vs.1.8%, p=0.015) (Figure1).

In the investigation of relationships between clinicopathologic factors and PTGBD status in the subgroup aged ≥65 years old, age was found to be an insignificant factor. In multivariate analysis in all patients, age was the only significant short-term prognostic factor (data not shown). In ananalysis of patients aged ≥65 years old, preoperative PTGBD was a significant short-term prognostic factor in univariate analysis (LOS: 10.43vs. 5.39days, p<0.0001), in addition to age, operation time, blood loss, and rate of conversion to laparotomy. Preoperative PTGBD and age remained as independent prognostic factors in multivariate analysis (Table 2).


Appropriate treatment of cholecystitis depends on the degree of local inflammation and damage to surrounding organs. Patients who do not receive definitive treatment with cholecystectomy during initial hospitalization have gallstone- or surgery-related 90-day and 1-year readmission rates of 29% and 35%, respectively[3].The 2013 Guidelines for Acute Cholangitis/Cholecystitis (ver. 2)[4] recommend early cholecystectomy in initial hospitalization as therapy for acute cholecystitis, depending on the severity. LCis the suggested procedure in cases of mild severity, while the procedural choice is indicated to depend on the ability of the endoscopic surgical team in cases of moderate severity.

At our hospital, early surgery is not always possible because of a shortage of surgeons and equipment. In such cases, conservative treatment with PTGBD is performed first and surgery is delayed until improvement of inflammation. This approach is supported by studies showing that early surgerymay be a contributory factor for conversion to laparotomy; therefore, preoperative PTGBD reduces inflammation and the risk of conversion to laparotomy[1,2].This background prompted us to investigate the impact of PTGBD on the outcome of LC for patients with cholecystitis in our hospital.

The indication for gallbladder drainage is moderate or severe cholecystitis, based on the severity criteria in the guidelines. Gallbladder drainage is a common and useful treatment in cases for which early surgery cannot be performed due to a high surgical risk, manpower and equipment constraints, or a patient declining surgery. A high surgical risk may be present in a case of severe cholecystitis, in which the top priority is to improve organ damage, but gallbladder drainage is also required as causal treatment. In such cases, an early operation may not be warranted and precedence must be given to reduction of jaundice or treatment of comorbidities. In our study, we found more diabetes cases in the PTGBD group than in the control group in an analysis of clinicopathologic features. This tendency may be related to the PTGBD cases being compromised hosts, but may also be because diabetic patients had to control their blood sugar before surgery.Koo et al[5]. suggested that the timing of surgery can be based on pathological findings:if the ambient gallbladder is edematous within 72 hours from onset, the gallbladder will be surgically separable from surrounding tissue; whereas if this situation is not present until more than 72 hours after onset, surgery may be difficult and drainage is a suitable option. Regarding manpower, early surgery depends on the availability of surgeons as a team, an accurate diagnosis from a primary-care clinician, and the availability of an anesthetist.

A survey by the Japan Society for Endoscopic Surgery(JSES)[6] showed an increasing trend in facilities choosing early LC, with 35% of respondents choosing early surgery for all cases and 54% for some cases (Figure2). However, LCcan be difficult to complete because of the hardness,swelling and tendency to bleed of the gallbladder wall[7]. Early LC in Japan has rates of conversion to laparotomy of 0-21.4%and complication rates of 8.4-10.3%, which are similar to those in elective surgery, but the average LOSof 4.4-8.9days after early LC is significantly shorter than that after elective surgery[8-16].Similarly, in the current study, the rates of conversion to laparotomy after early LC were almost equivalent to those in patients who first underwentPTGBD. However, the preoperative PTGBD group had a higher risk for complications and a longer stay after surgery.

Biliary tract infection develops frequently after preoperative biliary tract drainage for obstruction of the biliary tree by cancer[17,18], and biliary infection increases the frequency of SSI[19]. In our study, there was a significantly higher rate of incisional SSI in the PTGBD group, but no significant differences for organ/space SSI, intraoperative biliary injury, and postoperative bile spillage. However, preoperative PTGBD was found to be a significant short-term prognostic factor. We do not postpone discharge of patients based on incisional SSI, and thus we are unable to determine if the presence of this complication contributed to the elongation of the stay after surgery.

Drainage before surgery was also performed by ENBD/ENGBD or ERBD, but only PTGBD was a significant short-term prognostic factor in multivariate analysis. This may be because PTGBD is the only percutaneous method, with resident flora on the skin always being a risk for bacterial infection in percutaneous methods;or because PTGBD is the only method that affects the liver. Regardless, it seems that PTGBD is associated with prolongation of postoperative inflammatory reactions. However, the average period of 21.0 days between LC and PTGBD in this study seems to be appropriate based on previous studies. Thus, Kim et al[20] found significantly reduced rates of conversion to laparotomy and complications after LC performed an average of 19.9 days after PTGBD; and Katagiri et al[1] reported a 0% rate of conversion to laparotomy in LC performed 3weeks after PTGBD in cases in which LC was not the first treatment choice for acute cholecystitis.

In conclusion, preoperative PTGBD was found to correlate with extension of hospital stay after LC and to be an independent short-term prognostic factor in cholecystitis in patients aged 65 or over.

Conflict of Interest

None of the authors have a conflict of interest with regard to the work in the manuscript.


1Katagiri Y, Oniduka A, Iida Y. PTGBD and early laparoscopic cholecystectomy for acute cholecystitis. J Jpn Surg Assoc 2005;66: 343

2Iida Y, Katagiri Y, Kokubo K. Analysis of factors that influence the operation outcome of early laparoscopic cholecystectomy for acute cholecystitis. J Jpn Surg Assoc 2011; 72: 550-554

3Riall TS, Zhang D, Townsend Jr CM, Kuo YF, Goodwin JS. Failure to perform cholecystectomy for acute cholecystitis in elderly patients in associated with increased morbidity, mortality, and cost. J Am Coll Surg 2010; 210: 668-679

4Guidelines for management of acute cholangitis and cholecystitis, 2013. 2nd edn. Tokyo: Igakutosho-shuppan Ltd, 2013

5Koo KP, Thirlby RC. Laparoscopic cholecystectomy in acute cholecystitis:What is the optimal time for operation? Arch Surg 1996; 131:540-544

6Questionnaire about endoscopic surgery: 12th reports. J Jpn Soc Endosc Surg 2014; 19: 504

7Tokuyama Y, Osada S, Sanada Y. Laparoscopic-to-open cholecystectomy conversion at a Japanese prefectural university medical school. J Jpn Coll Surg 2009; 34: 562-565

8Yamamoto K, Morishima Y, Satomi D. Clinical outcome of emergency operations for acute cholecystitis during 11 years under the Japanese evidence-based guidelines for acute cholangitis and cholecystitis. J Abdom Emerg Med 2010; 30: 427-432

9Ueno N, Imanishi K, Hayami H. Inspection of the clinical guidelines: laparoscopic cholecystectomy for acute cholecystitis in the early post-onset phase. J Abdom Emerg Med 2010; 30: 433-436

10Iida Y, Fukunaga M, Tsumura H. Laparoscopic cholecystectomy for acute cholecystitis according to the Japanese guidelines. J Abdom Emerg Med 2010; 30: 437-441

11Matsuda S, Naito N, Sugimura Y. The introduction of laparoscopic cholecystectomy for acute cholecystitis. J Abdom Emerg Med 2009; 29: 471-476

12Tabata T, Fujimura M, Sato I. Laparoscopic cholecystectomy for acute cholecystitis. J Jpn Surg Assoc 2010; 71: 2236-2242

13Yokoyama Y, Yamaguchi A, Isogai M. Laparoscopic cholecystectomy: reports of 327 cases. J Jpn Pract Surg Soc 1995;56: 1571-1575

14Izuki Y, Otomo Y. Laparoscopic cholecystectomy. J Biliary Tract Pancreas 1992; 13: 1-5

15Taniguchi Y, Ido K, Kawamoto T. Laparoscopic cholecystectomy. J Biliary Tract Pancreas 1992; 13: 7-12

16Kimura T, Yoshida M, Sakuramachi S. Conversion laparotomy cases in laparoscopic cholecystectomy. J Biliary Tract Pancreas 1992; 13: 51-54

17Sudo T, Murakami Y, Uemura K, Hayashidani Y, Hashimoto Y, Ohge H, et al. Specific antibiotic prophylaxis based on bile cultures is required to prevent postoperative infectious complications in pancreatoduodenectomy patients who have undergone preoperative biliary drainage. World J Surg 2007; 31: 2230-2235

18Sugawara G, Ebata T, Yokoyama Y, Igami T, Takahashi Y, Takara D,et al. The effect of preoperative biliary drainage on infectious complications after hepatobiliary resection with cholangiojejunostomy. Surgery 2013; 153: 200-210

19Ferrero A, Lo Tesoriere R, Vigano L, Caggiano L, Sgotto E, Capussotti L.Preoperative biliary drainage increases infectious complications after hepatectomy for proximal bile duct tumor obstruction. World J Surg 2009; 33: 318-325

20Kim HO, Ho Son B, Yoo CH, Ho Shin J. Impact of delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis. Surg Laparosc Endosc Percutan Tech 2009; 19: 20-24

Peer reviewer:Bum Soo Kim, MD. PhD, Department of Surgery, Kyung Hee University School of Medicine and the Kyung Hee University Hospital at Gangdong,149 Sangil-dong, Gangdong-gu, Seoul 134-727, Korea.


  • There are currently no refbacks.

Creative Commons License
This work is licensed under a Creative Commons Attribution 3.0 License.