Introduction
A free-standing cancer center still manages and treats general surgical problems but has the added complexity of patients with a cancer diagnosis. Patients with cancer represent a patient population that may not be candidates for early cholecystectomy (EC), and very little has been written about patients with cancer who present with acute cholecystitis (AC). Patients with cancer on active chemotherapy commonly present with neutropenia and thrombocytopenia, making them susceptible to impaired healing and bleeding. Neutropenic cholecystitis has been associated with higher postsurgical mortality rates, and thrombocytopenia can complicate operation due to difficulties with hemostasis.1 Technical factors associated with advanced-stage malignancy, such as tumor invasion of the gallbladder and porta hepatis, peritoneal carcinomatosis, and malignant ascites, present challenges to cholecystectomy, making certain patients ineligible for operation. Additionally, the poor prognosis of patients with advanced malignancy may alter surgical decision making as these patients may prefer non-surgical options over potential, postsurgical complications. The optimal management of patients with cancer with AC remains undefined.
In contrast, much is written about patients without cancer presenting with AC. The standard of care for most surgeons is to perform EC when patients present to the hospital. Unfortunately, patients who are not ideal surgical candidates due to delayed presentation and increased tissue inflammation, poor physiologic reserve, or functional capacity may prompt surgeons to treat such patients non-operatively on their initial encounter and pursue elective cholecystectomy after discharging the patient from the hospital. Although a recent meta-analysis showed that EC and interval cholecystectomy (IC) show no difference in morbidity and mortality, current evidence suggests that EC is favored because of reduced hospital stay and reduced risk of readmission.2–5 The advent of interventional radiology techniques introduced percutaneous cholecystostomy tubes (PCT) as valuable adjunctive treatment in patients who are poor surgical candidates.6 7 PCT placement works by decreasing distension of the gallbladder, mechanically draining bile, and allowing gallbladder wall inflammation and ischemia to subside. With the exception of sepsis from AC, large studies generally agree that PCT is an effective treatment for patients in whom cholecystectomy would not be considered.8–11 The need for IC has not been clearly demonstrated and data vary widely. Some authors have suggested IC will be needed due to recurrent symptoms from cystic duct obstruction in 21%–44% of patients, and others suggest that no further operation may be needed as the reported rate of success without relapse ranges between 55% and 88%.12–14 Thus, it is unclear if surgeons should perform cholecystectomy in potentially poor surgical candidates after PCT placement to prevent recurrent cholecystitis if less than half of patients experience a relapse in symptoms.
Our present study is exploratory, and its purpose was to compare the proportions of patients with cancer presenting with AC treated successfully with antibiotics (ABX) versus PCTs and their associated patient factors in our institution. Our secondary aim was to analyze the proportion of patients who returned for IC versus those who did not and their associated patient factors. We hypothesize that PCT, when compared with ABX alone, will be more effective in resolving AC in immunocompromised patients. We also hypothesize that PCT may be a bridge to IC.