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 Sheath is inserted and gradually withdrawn while contrast material is injected.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:
-
Bile peritonitis
-
Hemobilia
-
Gallbladder perforation
-
Vagal effect due to catheter placement
-
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.
