Background
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 Percutaneous Cholangiography, Percutaneous Biliary Drainage, and Biliary Stenting.
Indications
Cholecystostomy is used as a temporizing measure in critically ill patients with acute cholecystitis who cannot undergo cholecystectomy. [3, 4, 5] After symptoms resolve and the patient's condition stabilizes, definitive treatment is still gallbladder removal. Some studies have not found percutaneous cholecystostomy to have substantial advantages over conservative treatment in this setting. [6, 7] Some debate remains regarding the clinical utility of and precise indications for this procedure. [8]
Some have suggested that percutaneous cholecystostomy may be a worthwhile option for definitive treatment in selected high-risk patients with acute calculous cholecystitis (eg, those who are elderly [9] or who have elevated alkaline phosphatase levels or a history of coronary artery disease). [10, 11, 12, 13, 14, 15] Morbidity and mortality appear to be increased in comparison with cholecystectomy. [16]
In acalculous cholecystitis, percutaneous drainage may be the only treatment required. [17, 18]
Outcomes
In a retrospective study of patients with acute cholecystitis who were at very high surgical risk, Furtado et al found that although percutaneous cholecystostomy was a life-saving maneuver, it gave rise to significant morbidity, with a 44% rate of choledocholithiasis, a 27% rate of tube dislodgment, and a 23% rate of postoperative abscess. [19]
In a retrospective review of long-term outcomes in 324 patients who had undergone percutaneous cholecystostomy for acute cholecystitis (n = 270), perforated cholecystitis (n = 22), emphysematous cholecystitis (n = 18), or other indications (n = 14), Bundy et al reported a technical success rate of 100%. [20] After tube placement, 96 patients underwent definitive cholecystectomy, 94 died, 36 had a patent cystic duct on follow-up cholangiography and subsequent tube removal, 14 underwent cholecystoscopy with stone removal, and three had a liver transplant. Clinical resolution of acute cholecystitis was noted in all patients.
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Tract evaluation for cholecystostomy catheter removal. Sheath is inserted and gradually withdrawn while contrast material is injected. No leakage of contrast medium is seen. Note free flow of contrast agent to common bile duct (CBD) and duodenum.
