Natural Course of Acute Cholecystitis in Patients Treated With Percutaneous Transhepatic Gallbladder Drainage Without Elective Cholecystectomy

  • Yu-Liang Hung
  • Sio-Wai Chong
  • Chi-Tung Cheng
  • Chien-Hung Liao
  • Chih-Yuan Fu
  • Chi-Hsun Hsieh
  • Ta-Sen Yeh
  • Chun-Nan Yeh
  • Yi-Yin Jan
  • Shang-Yu WangEmail author
Original Article



Percutaneous transhepatic gallbladder drainage (PTGBD) is an alternative treatment for acute cholecystitis (AC). We aimed to understand the natural course of AC in patients treated with PTGBD but without later definitive treatments, such as laparoscopic cholecystectomy.


This was a retrospective study of the period from June 2010 to December 2016, during which time 2371 patients were diagnosed with AC and 625 received PTGBD treatment. Among the 625 patients, 237 received no definitive treatment. A biliary event after the initial AC episode was the outcome of interest. In addition, the competing risk of death unrelated to biliary causes was present in the cohort. Therefore, a competing risk model was applied for analysis.


The cumulative incidence of biliary events was 29.8% with a median of 4.27 months, while the competing event, i.e., death unrelated to a biliary event, was noted in 14.9% of patients with a median 23.54 months. The risk factors of biliary events were prolonged PTGBD indwelling and an abnormal PTGBD cholangiogram. The risk factors of death unrelated to a biliary event included a high Charlson comorbidity index and the initial AC severity.


Definitive cholecystectomy is still recommended for patients undergoing PTGBD treatment due to the high incidence of later biliary events. A thorough preoperative evaluation is necessary for those patients before elective cholecystectomy because of the inferior life expectancy and physical status.


Acute cholecystitis Percutaneous transhepatic gallbladder drainage Cholecystectomy 



We would like to thank the CGMH Acute Abdomen Database organization and database managers, Shu-Ping Liao, Ching-Hua Hsu, Chun-Ju Chen, Fen-Ping Kao, and Hui-Chen Tien.

Author Contributions

Data acquisition: YL Hung and SW Chong. Manuscript drafting: YL Hung and SY Wang. Figure and table preparation: CH Liao, CT Cheng, and CY FU. Statistical analysis: SY Wang. Manuscript structuring: CN Yeh, TS Yeh, and YY Jan. Final approval: SY Wang and CH Hsieh.

Compliance with Ethical Standards

The Institutional Review Board of CGMH approved the study.

Conflict of Interest

The authors declare that they have no conflicts of interest.

Supplementary material

11605_2019_4213_MOESM1_ESM.docx (7.7 mb)
Supplementary Figure 1 (DOCX 7866 kb)


  1. 1.
    Tazuma S. Gallstone disease: Epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic). Best practice & research Clinical gastroenterology. 2006;20(6):1075-83. Scholar
  2. 2.
    Shaffer EA. Gallstone disease: Epidemiology of gallbladder stone disease. Best practice & research Clinical gastroenterology. 2006;20(6):981–96. Scholar
  3. 3.
    Chen CH, Huang MH, Yang JC, Nien CK, Etheredge GD, Yang CC, Yeh YH, Wu HS, Chou DA, Yueh SK. Prevalence and risk factors of gallstone disease in an adult population of Taiwan: an epidemiological survey. Journal of gastroenterology and hepatology. 2006;21(11):1737-43. Scholar
  4. 4.
    Okamoto K, Suzuki K, Takada T, Strasberg SM, Asbun HJ, Endo I, Iwashita Y, Hibi T, Pitt HA, Umezawa A, Asai K, Han HS, Hwang TL, Mori Y, Yoon YS, Huang WS, Belli G, Dervenis C, Yokoe M, Kiriyama S, Itoi T, Jagannath P, Garden OJ, Miura F, Nakamura M, Horiguchi A, Wakabayashi G, Cherqui D, de Santibanes E, Shikata S, Noguchi Y, Ukai T, Higuchi R, Wada K, Honda G, Supe AN, Yoshida M, Mayumi T, Gouma DJ, Deziel DJ, Liau KH, Chen MF, Shibao K, Liu KH, Su CH, Chan ACW, Yoon DS, Choi IS, Jonas E, Chen XP, Fan ST, Ker CG, Gimenez ME, Kitano S, Inomata M, Hirata K, Inui K, Sumiyama Y, Yamamoto M. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. Journal of hepato-biliary-pancreatic sciences. 2018;25(1):55-72. Scholar
  5. 5.
    Ansaloni L, Pisano M, Coccolini F, Peitzmann AB, Fingerhut A, Catena F, Agresta F, Allegri A, Bailey I, Balogh ZJ, Bendinelli C, Biffl W, Bonavina L, Borzellino G, Brunetti F, Burlew CC, Camapanelli G, Campanile FC, Ceresoli M, Chiara O, Civil I, Coimbra R, De Moya M, Di Saverio S, Fraga GP, Gupta S, Kashuk J, Kelly MD, Koka V, Jeekel H, Latifi R, Leppaniemi A, Maier RV, Marzi I, Moore F, Piazzalunga D, Sakakushev B, Sartelli M, Scalea T, Stahel PF, Taviloglu K, Tugnoli G, Uraneus S, Velmahos GC, Wani I, Weber DG, Viale P, Sugrue M, Ivatury R, Kluger Y, Gurusamy KS, Moore EE. 2016 WSES guidelines on acute calculous cholecystitis. World journal of emergency surgery : WJES. 2016;11:25. Scholar
  6. 6.
    Internal Clinical Guidelines T. National Institute for Health and Care Excellence: Clinical Guidelines. Gallstone Disease: Diagnosis and Management of Cholelithiasis, Cholecystitis and Choledocholithiasis. London: National Institute for Health and Care Excellence (UK) Copyright (c) National Clinical Guideline Centre, 2014.; 2014.Google Scholar
  7. 7.
    Horn T, Christensen SD, Kirkegard J, Larsen LP, Knudsen AR, Mortensen FV. Percutaneous cholecystostomy is an effective treatment option for acute calculous cholecystitis: a 10-year experience. HPB : the official journal of the International Hepato Pancreato Biliary Association. 2015;17(4):326-31. Scholar
  8. 8.
    Bergman S, Al-Bader M, Sourial N, Vedel I, Hanna WC, Bilek AJ, Galatas C, Marek JE, Fraser SA. Recurrence of biliary disease following non-operative management in elderly patients. Surgical endoscopy. 2015;29(12):3485-90. Scholar
  9. 9.
    Chang YR, Ahn YJ, Jang JY, Kang MJ, Kwon W, Jung WH, Kim SW. Percutaneous cholecystostomy for acute cholecystitis in patients with high comorbidity and re-evaluation of treatment efficacy. Surgery. 2014;155(4):615-22. Scholar
  10. 10.
    Sanjay P, Mittapalli D, Marioud A, White RD, Ram R, Alijani A. Clinical outcomes of a percutaneous cholecystostomy for acute cholecystitis: a multicentre analysis. HPB : the official journal of the International Hepato Pancreato Biliary Association. 2013;15(7):511-6. Scholar
  11. 11.
    Wang CH, Wu CY, Yang JC, Lien WC, Wang HP, Liu KL, Wu YM, Chen SC. Long-Term Outcomes of Patients with Acute Cholecystitis after Successful Percutaneous Cholecystostomy Treatment and the Risk Factors for Recurrence: A Decade Experience at a Single Center. PloS one. 2016;11(1):e0148017. Scholar
  12. 12.
    Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, Pitt HA, Garden OJ, Kiriyama S, Hata J, Gabata T, Yoshida M, Miura F, Okamoto K, Tsuyuguchi T, Itoi T, Yamashita Y, Dervenis C, Chan AC, Lau WY, Supe AN, Belli G, Hilvano SC, Liau KH, Kim MH, Kim SW, Ker CG. TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). Journal of hepato-biliary-pancreatic sciences. 2013;20(1):35-46. Scholar
  13. 13.
    Kiriyama S, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Pitt HA, Gouma DJ, Garden OJ, Buchler MW, Yokoe M, Kimura Y, Tsuyuguchi T, Itoi T, Yoshida M, Miura F, Yamashita Y, Okamoto K, Gabata T, Hata J, Higuchi R, Windsor JA, Bornman PC, Fan ST, Singh H, de Santibanes E, Gomi H, Kusachi S, Murata A, Chen XP, Jagannath P, Lee S, Padbury R, Chen MF, Dervenis C, Chan AC, Supe AN, Liau KH, Kim MH, Kim SW. TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos). Journal of hepato-biliary-pancreatic sciences. 2013;20(1):24-34. Scholar
  14. 14.
    Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102-11. Scholar
  15. 15.
    Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. Journal of clinical epidemiology. 1994;47(11):1245-51.CrossRefGoogle Scholar
  16. 16.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. Journal of chronic diseases. 1987;40(5):373–-83.CrossRefGoogle Scholar
  17. 17.
    Austin PC, Lee DS, Fine JP. Introduction to the Analysis of Survival Data in the Presence of Competing Risks. Circulation. 2016;133(6):601-9. Scholar
  18. 18.
    Wiggins T, Markar SR, Mackenzie H, Jamel S, Askari A, Faiz O, Karamanakos S, Hanna GB. Evolution in the management of acute cholecystitis in the elderly: population-based cohort study. Surgical endoscopy. 2018;32(10):4078-86. Scholar
  19. 19.
    Papis D, Khalifa E, Bhogal R, Nair A, Khan S, Hamady Z, Ahmed J, Marangoni G. Is Percutaneous Cholecystostomy a Good Alternative Treatment for Acute Cholecystitis in High-Risk Patients? The American surgeon. 2017;83(6):623-7.Google Scholar
  20. 20.
    Lu P, Chan CL, Yang NP, Chang NT, Lin KB, Lai KR. Outcome comparison between percutaneous cholecystostomy and cholecystectomy: a 10-year population-based analysis. BMC surgery. 2017;17(1):130. Names in bold designate as co-first authors.CrossRefGoogle Scholar
  21. 21.
    Popowicz A, Lundell L, Gerber P, Gustafsson U, Pieniowski E, Sinabulya H, Sjodahl K, Tsekrekos A, Sandblom G. Cholecystostomy as Bridge to Surgery and as Definitive Treatment or Acute Cholecystectomy in Patients with Acute Cholecystitis. Gastroenterology research and practice. 2016;2016:3672416. Scholar
  22. 22.
    Hall BR, Armijo PR, Krause C, Burnett T, Oleynikov D. Emergent cholecystectomy is superior to percutaneous cholecystostomy tube placement in critically ill patients with emergent calculous cholecystitis. American journal of surgery. 2018;216(1):116-9. Scholar
  23. 23.
    Cull JD, Velasco JM, Czubak A, Rice D, Brown EC. Management of acute cholecystitis: prevalence of percutaneous cholecystostomy and delayed cholecystectomy in the elderly. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2014;18(2):328-33. Scholar
  24. 24.
    Miura F, Takada T, Kawarada Y, Nimura Y, Wada K, Hirota M, Nagino M, Tsuyuguchi T, Mayumi T, Yoshida M, Strasberg SM, Pitt HA, Belghiti J, de Santibanes E, Gadacz TR, Gouma DJ, Fan ST, Chen MF, Padbury RT, Bornman PC, Kim SW, Liau KH, Belli G, Dervenis C. Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines. Journal of hepato-biliary-pancreatic surgery. 2007;14(1):27-34. Scholar
  25. 25.
    Lin WC, Chang CW, Chu CH. Percutaneous cholecystostomy for acute cholecystitis in high-risk elderly patients. The Kaohsiung journal of medical sciences. 2016;32(10):518-25. Scholar
  26. 26.
    Hsieh YC, Chen CK, Su CW, Chan CC, Huo TI, Liu CJ, Fang WL, Lee KC, Lin HC. Outcome after percutaneous cholecystostomy for acute cholecystitis: a single-center experience. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2012;16(10):1860-8. Scholar
  27. 27.
    Pang KW, Tan CH, Loh S, Chang KY, Iyer SG, Madhavan K, Kow WC. Outcomes of Percutaneous Cholecystostomy for Acute Cholecystitis. World journal of surgery. 2016;40(11):2735-44. Scholar
  28. 28.
    Winbladh A, Gullstrand P, Svanvik J, Sandstrom P. Systematic review of cholecystostomy as a treatment option in acute cholecystitis. HPB : the official journal of the International Hepato Pancreato Biliary Association. 2009;11(3):183-93. Scholar
  29. 29.
    Hatzidakis AA, Prassopoulos P, Petinarakis I, Sanidas E, Chrysos E, Chalkiadakis G, Tsiftsis D, Gourtsoyiannis NC. Acute cholecystitis in high-risk patients: percutaneous cholecystostomy vs conservative treatment. European radiology. 2002;12(7):1778-84. Scholar
  30. 30.
    Jang WS, Lim JU, Joo KR, Cha JM, Shin HP, Joo SH. Outcome of conservative percutaneous cholecystostomy in high-risk patients with acute cholecystitis and risk factors leading to surgery. Surgical endoscopy. 2015;29(8):2359-64. Scholar
  31. 31.
    Crnich CJ, Drinka P. Medical device-associated infections in the long-term care setting. Infectious disease clinics of North America. 2012;26(1):143-64. Scholar
  32. 32.
    Roslyn JJ, DenBesten L, Thompson JE, Jr., Silverman BF. Roles of lithogenic bile and cystic duct occlusion in the pathogenesis of acute cholecystitis. American journal of surgery. 1980;140(1):126-30.CrossRefGoogle Scholar
  33. 33.
    Morris CR, Hohf RP, Ivy AC. An experimental study of the role of stasis in the etiology of cholecystitis. Surgery. 1952;32(4):673-85.Google Scholar
  34. 34.
    Lokhandwala S, McCague N, Chahin A, Escobar B, Feng M, Ghassemi MM, Stone DJ, Celi LA. One-year mortality after recovery from critical illness: A retrospective cohort study. PloS one. 2018;13(5):e0197226. Names in bold designate as co-first authors.CrossRefGoogle Scholar
  35. 35.
    Abu-Kaf H, Mizrakli Y, Novack V, Dreiher J. Long-Term Survival of Young Patients Surviving ICU Admission With Severe Sepsis. Critical care medicine. 2018;46(8):1269-75. Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  1. 1.School of Traditional Chinese MedicineChang Gung UniversityTaoyuanRepublic of China
  2. 2.Division of General SurgeryChang Gung Memorial HospitalTaoyuanRepublic of China
  3. 3.Division of Trauma and Emergency Surgery, General SurgeryChang Gung Memorial HospitalTaoyuanRepublic of China
  4. 4.Graduate Institute of Clinical Medical SciencesChang Gung UniversityTaoyuanRepublic of China
  5. 5.School of MedicineChang Gung UniversityTaoyuanRepublic of China

Personalised recommendations