Percutaneous Cholecystostomy 

  • Author: Atif Rana, MBBS; Chief Editor: Kyung J Cho, MD, FACR   more...
 
Updated: Jan 22, 2010
 

Overview

Over the past few decades, biliary interventions have evolved a great deal. Opacification of the biliary system was first reported in 1921 with direct puncture of the gallbladder. Subsequent reports described direct percutaneous biliary puncture. The technique was revolutionized in 1960s with the introduction of fine-gauge (22- to 23-gauge) needles.

During the 1970s, percutaneous biliary drainage (PBD) for obstructive jaundice and percutaneous treatment of stone disease was introduced. Percutaneous cholecystostomy was first described in the 1980s. With the advent of metallic and plastic internal stents, further applications in the treatment of biliary diseases were developed.

Current percutaneous biliary interventions include percutaneous transhepatic cholangiography (PTC) and biliary drainage to manage benign[1] and malignant obstruction and percutaneous cholecystostomy.[2] Percutaneous treatment of biliary stone disease with or without choledochoscopy is still performed in selected cases. Other applications include cholangioplasty for biliary strictures, biopsy of the biliary duct, and management of complications from laparoscopic cholecystectomy and liver transplantation.

This article outlines the procedure for percutaneous cholecystostomy. For descriptions of other biliary interventions, see eMedicine articles Percutaneous Cholangiography, Percutaneous Biliary Drainage, and Biliary Stenting.

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Indications

  • Cholecystostomy is used as a temporizing measure in critically ill patients with acute cholecystitis who cannot undergo cholecystectomy. After the symptoms resolve and the patient's condition is stabilized, definite treatment is still gallbladder removal.
  • In acalculous cholecystitis, percutaneous drainage may be the only treatment required.
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Technique

  • The procedure is performed under ultrasonographic and fluoroscopic guidance, though it can be performed with only ultrasonographic guidance.[10]
  • Most clinicians prefer a transhepatic approach because a transperitoneal approach poses a risk of bile peritonitis. However, a transperitoneal approach can be used if the gallbladder is very distended.
  • The gallbladder can be punctured with a trocar needle-catheter or by using a Seldinger technique. Various catheters in use include the Hawkins accordion catheter and the McGahan catheter; however, an all-purpose pigtail drainage catheter can be used safely.
  • Bile samples are collected for Gram staining and cultures.
  • A small amount of contrast agent is injected to confirm the position of the catheter, and the catheter is secured to skin by using suture material. It is left to drain by gravity.
  • Definitive treatment for calculous cholecystitis is gallbladder removal. If surgery is not considered, as in acalculous cholecystitis, the tube can be removed after signs of infection resolve. The time for tract maturation is not well established. Davis et al advocate 7-10 days to allow tract maturation, though they do not describe whether tract maturation they evaluated by injecting contrast material.[11]
  • At the author's institution, the cholecystostomy catheter is generally removed after 2-3 weeks. The tube is clamped for about 48 hours to evaluate the patency of the cystic duct and to observe for any signs and symptoms suggestive of cystic duct obstruction. If the patient does not develop any complications, such as fever, pain, or an increasing WBC count, the tube is removed. Tract maturation is evaluated before the catheter is removed by injecting contrast material through the catheter while the catheter is pulled over a wire (see image below). If extravasation into the peritoneum is noted, the catheter should be reinserted to prevent bile peritonitis. A follow-up study is performed in a few weeks in a similar fashion to evaluate for tube removal. Tract evaluation for cholecystostomic catheter remTract evaluation for cholecystostomic catheter removal. A sheath is inserted and gradually withdrawn while contrast material is injected. No leakage of the contrast medium is seen. Note the free flow of the contrast agent to the common bile duct (CBD) and duodenum.
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Complications

  • Complications include bile peritonitis, hemobilia, gallbladder perforation, and a vagal effect due to catheter placement.
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Contributor Information and Disclosures
Author

Atif Rana, MBBS  Assistant Professor, Department of Radiology, Shifa College of Medicine, Islamabad, Pakistan

Atif Rana, MBBS is a member of the following medical societies: Radiological Society of North America

Disclosure: Nothing to disclose.

Specialty Editor Board

Gary P Siskin, MD  Professor and Chairman, Department of Radiology, Albany Medical College

Gary P Siskin, MD is a member of the following medical societies: American College of Radiology, Cardiovascular and Interventional Radiological Society of Europe, Radiological Society of North America, and Society of Interventional Radiology

Disclosure: Nothing to disclose.

Bernard D Coombs, MB, ChB, PhD  Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Douglas M Coldwell, MD, PhD  Professor of Radiology, Director, Division of Vascular and Interventional Radiology, University of Louisville School of Medicine

Douglas M Coldwell, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American College of Radiology, American Heart Association, American Physical Society, American Roentgen Ray Society, Society of Cardiovascular and Interventional Radiology, Southwest Oncology Group, and Special Operations Medical Association

Disclosure: Sirtex, Inc. Consulting fee Speaking and teaching

Robert M Krasny, MD  Resolution Imaging Medical Corporation

Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America

Disclosure: Nothing to disclose.

Chief Editor

Kyung J Cho, MD, FACR  William Martel Professor of Radiology, Interventional Radiology Fellowship Director, University of Michigan Health System

Kyung J Cho, MD, FACR is a member of the following medical societies: American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America

Disclosure: Nothing to disclose.

References

  1. Kocher M, Cerna M, Havlík R, Kral V, Gryga A, Duda M. Percutaneous treatment of benign bile duct strictures. Eur J Radiol. May 2007;62(2):170-4. [Medline].

  2. Link BC, Yekebas EF, Bogoevski D, et al. Percutaneous transhepatic cholangiodrainage as rescue therapy for symptomatic biliary leakage without biliary tract dilation after major surgery. J Gastrointest Surg. Feb 2007;11(2):166-70. [Medline].

  3. Faylona JM, Qadir A, Chan AC, Lau JY, Chung SC. Small-bowel perforations related to endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy. Endoscopy. Sep 1999;31(7):546-9. [Medline].

  4. Gabelmann A, Hamid H, Brambs HJ, Rieber A. Metallic stents in benign biliary strictures: long-term effectiveness and interventional management of stent occlusion. AJR Am J Roentgenol. Oct 2001;177(4):813-7. [Medline].

  5. Lopez RR Jr, Cosenza CA, Lois J, et al. Long-term results of metallic stents for benign biliary strictures. Arch Surg. Jun 2001;136(6):664-9. [Medline].

  6. Navaneethan U, Jayanthi V. Endoscopic management of biliary leaks. The answer for the future. Minerva Gastroenterol Dietol. Jun 2008;54(2):141-50. [Medline].

  7. Gupta K, Mallery S, Hunter D, Freeman ML. Endoscopic ultrasound and percutaneous access for endoscopic biliary and pancreatic drainage after initially failed ERCP. Rev Gastroenterol Disord. Winter 2007;7(1):22-37. [Medline].

  8. Kaskarelis IS, Papadaki MG, Papageorgiou GN, Limniati MD, Malliaraki NE, Piperopoulos PN. Long-term follow-up in patients with malignant biliary obstruction after percutaneous placement of uncovered wallstent endoprostheses. Acta Radiol. Sep 1999;40(5):528-33. [Medline].

  9. Lee BH, Choe DH, Lee JH, Kim KH, Chin SY. Metallic stents in malignant biliary obstruction: prospective long-term clinical results. AJR Am J Roentgenol. Mar 1997;168(3):741-5. [Medline].

  10. Bakkaloglu H, Yanar H, Guloglu R, et al. Ultrasound guided percutaneous cholecystostomy in high-risk patients for surgical intervention. World J Gastroenterol. Nov 28 2006;12(44):7179-82. [Medline].

  11. Davis CA, Landercasper J, Gundersen LH, Lambert PJ. Effective use of percutaneous cholecystostomy in high-risk surgical patients: techniques, tube management, and results. Arch Surg. Jul 1999;134(7):727-31; discussion 731-2.

  12. Baijal SS, Dhiman RK, Gupta S, et al. Percutaneous transhepatic biliary drainage in the management of obstructive jaundice. Trop Gastroenterol. Oct-Dec 1997;18(4):167-71. [Medline].

  13. Becker CD, Glattli A, Maibach R, Baer HU. Percutaneous palliation of malignant obstructive jaundice with the Wallstent endoprosthesis: follow-up and reintervention in patients with hilar and non-hilar obstruction. J Vasc Interv Radiol. Sep-Oct 1993;4(5):597-604. [Medline].

  14. Bezzi M, Zolovkins A, Cantisani V, et al. New ePTFE/FEP-covered stent in the palliative treatment of malignant biliary obstruction. J Vasc Interv Radiol. Jun 2002;13(6):581-9. [Medline].

  15. Boggi U, Di Candio G, Campatelli A, et al. Percutaneous cholecystostomy for acute cholecystitis in critically ill patients. Hepatogastroenterology. Jan-Feb 1999;46(25):121-5. [Medline].

  16. Chang L, Moonka R, Stelzner M. Percutaneous cholecystostomy for acute cholecystitis in veteran patients. Am J Surg. Sep 2000;180(3):198-202. [Medline].

  17. Coons H. Metallic stents for the treatment of biliary obstruction: a report of 100 cases. Cardiovasc Intervent Radiol. Nov-Dec 1992;15(6):367-74. [Medline].

  18. Costamagna G, Pandolfi M, Mutignani M, Spada C, Perri V. Long-term results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents. Gastrointest Endosc. Aug 2001;54(2):162-8. [Medline].

  19. Davids PH, Groen AK, Rauws EA, Tytgat GN, Huibregtse K. Randomised trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction. Lancet. Dec 19-26 1992;340(8834-8835):1488-92. [Medline].

  20. Doctor N, Dick R, Rai R, et al. Results of percutaneous plastic stents for malignant distal biliary obstruction following failed endoscopic stent insertion and comparison with current literature on expandable metallic stents. Eur J Gastroenterol Hepatol. Jul 1999;11(7):775-80. [Medline].

  21. Gazzaniga GM, Faggioni A, Bondanza G, Bagarolo C, Filauro M. Percutaneous transhepatic biliary drainage--twelve years' experience. Hepatogastroenterology. Apr 1991;38(2):154-9. [Medline].

  22. Harbin WP, Mueller PR, Ferrucci JT Jr. Transhepatic cholangiography: complicatons and use patterns of the fine-needle technique: a multi-institutional survey. Radiology. Apr 1980;135(1):15-22. [Medline].

  23. Hatjidakis AA, Karampekios S, Prassopoulos P, et al. Maturation of the tract after percutaneous cholecystostomy with regard to the access route. Cardiovasc Intervent Radiol. Jan-Feb 1998;21(1):36-40. [Medline].

  24. Kandarpa K, Aruny JE. Handbook of Interventional Radiologic Procedures. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2001.

  25. Kiviniemi H, Makela JT, Autio R, et al. Percutaneous cholecystostomy in acute cholecystitis in high-risk patients: an analysis of 69 patients. Int Surg. Oct-Dec 1998;83(4):299-302. [Medline].

  26. Lillemoe KD, Melton GB, Cameron JL, et al. Postoperative bile duct strictures: management and outcome in the 1990s. Ann Surg. Sep 2000;232(3):430-41. [Medline].

  27. Moore AV Jr, Illescas FF, Mills SR, et al. Percutaneous dilation of benign biliary strictures. Radiology. Jun 1987;163(3):625-8. [Medline].

  28. Mueller PR, Ferrucci JT Jr, Teplick SK, et al. Biliary stent endoprosthesis: analysis of complications in 113 patients. Radiology. Sep 1985;156(3):637-9. [Medline].

  29. Mueller PR, vanSonnenberg E, Ferrucci JT Jr, et al. Biliary stricture dilatation: multicenter review of clinical management in 73 patients. Radiology. Jul 1986;160(1):17-22. [Medline].

  30. Schoder M, Rossi P, Uflacker R, et al. Malignant biliary obstruction: treatment with ePTFE-FEP- covered endoprostheses initial technical and clinical experiences in a multicenter trial. Radiology. Oct 2002;225(1):35-42. [Medline].

  31. Yee AC, Ho CS. Complications of percutaneous biliary drainage: benign vs malignant diseases. AJR Am J Roentgenol. Jun 1987;148(6):1207-9. [Medline].

 
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Tract evaluation for cholecystostomic catheter removal. A sheath is inserted and gradually withdrawn while contrast material is injected. No leakage of the contrast medium is seen. Note the free flow of the contrast agent to the common bile duct (CBD) and duodenum.
 
 
 
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