Percutaneous Cholecystostomy
Updated: Jan 21, 2022
Author: Thomas M Fahrbach, MD; Chief Editor: Kyung J Cho, MD, FACR, FSIR
Overview
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.
Technique
Percutaneous Cholecystostomy
Percutaneous cholecystostomy is commonly performed under the guidance of ultrasonography (US) and fluoroscopy, though it can also be performed with only US guidance.[21, 22]
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 greatly 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. The catheter is secured to skin with suture material and left to drain through 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 advocated allowing 7-10 days for tract maturation, though they did not describe whether they evaluated tract maturation by injecting contrast material.[23]
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 white blood cell (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 the 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 similar fashion a few weeks later to evaluate for tube removal.
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.
Complications
Complications of percutaneous cholecystostomy include the following:
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Bile peritonitis
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Hemobilia
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Gallbladder perforation
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Vagal effect due to catheter placement