Percutaneous cholecystostomy
Dr. Ali Asgar Sabir
Percutaneous cholecystostomy (PC) stands as a vital procedure in the treatment of acute cholecystitis (AC), particularly for patients who may not immediately undergo laparoscopic cholecystectomy. Administered by interventional radiologists, PC offers an effective means of decompressing the gallbladder in cases of AC. This intervention encompasses various approaches, including percutaneous transhepatic gallbladder drainage, percutaneous transperitoneal gallbladder drainage, and percutaneous transhepatic gallbladder aspiration. Originating in the 1970s for cases of obstructive jaundice, PC gradually found application in AC during the 1980s.
Presently, it serves as a viable alternative for individuals unfit for immediate surgical intervention due to factors like severe sepsis, shock, or significant comorbidities. Notably, the World Society of Emergency Surgery (WSES) guidelines endorse PC as a valid option in such scenarios, reinforcing its importance in the realm of emergency medicine.
Indications and contraindications of percutaneous cholecystostomy:
| Indications | Contraindications |
|---|---|
| Patients unsuitable for immediate laparoscopic cholecystectomy due to severe sepsis, shock, or multiple comorbidities | Coagulopathy (correctable with transfusions) |
| AC patients not fit for emergency cholecystectomy | Allergy to iodinated contrast (ultrasound-guided PC an option) |
| AC patients with severe comorbidities (per WSES guidelines) | Ascites (can be treated with paracentesis prior to PC) |
| Gallbladder tightly packed with gallstones |
Approach for percutaneous cholecystostomy:
| Technique | Advantages | Considerations |
|---|---|---|
| Transhepatic (most commonly used) | 1. More anatomic fixation 2. Direct penetration of liver | 1. May be unsuitable for distended gallbladders 2. Technical difficulties in some cases |
| Transperitoneal | 1. Suitable for patients with distended gallbladders directly adhering to abdominal wall 2. Beneficial in cases with coagulopathy or liver metastasis 3. Debate ongoing, choice depends on patient anatomy | 1. Higher risk of complications like bile leakage and recurrence of cholecystitis 2. Right colon may pose challenges 3. Technically more difficult |
Patient investigation, procedure and post-procedure care in percutaneous cholecystostomy:
| Parameters | Keypoints |
|---|---|
| Coagulation abnormalities | Correct prior to procedure (platelets >50,000, INR <1.5) |
| Prophylactic antibiotics | Administered 12-24 hours before procedure |
| Imaging Review | Cross-sectional MR and CT images evaluated for anatomy |
| Ultrasound | Used to examine gallbladder wall thickening and bowel interference |
| Sedation | IV midazolam and fentanyl can be used for conscious sedation |
| Puncture | Access needle (22-18 gauge) used to puncture gallbladder |
| Confirmation | Bile aspiration or contrast injection under fluoroscopy |
| Drain Insertion | 8 or 10F drain catheter with multiple side holes for drainage |
| Decompression | Bile sent for cultures and catheter left for gravity drainage |
| Cholecystogram | Optional at the time of the procedure if using fluoroscopy |
| Cholecystography | Done at a later date recommended to evaluate catheter position and cystic duct patency |
| Tube Preservation | Some authors advocate tube preservation until surgery |
| Routine Replacements | Necessary to prevent malfunction or obstruction of the drainage tube |
| Tube Removal | Increasing evidence supports removal after AC resolution |
| Tract Maturity | Tract matures in 3-4 weeks, preventing bile leakage |
| Impact on Recurrence | Prolonged tube indwelling a factor for recurrent biliary events |
| Clinical Outcomes | Removal has no significant impact on outcomes |
Complications related to percutaneous cholecystostomy:
| Complications | Description |
|---|---|
| Time to Improvement | Median of 3-4 days after Percutaneous drain insertion |
| Minor Complications | Tube dislodgement (4.5-15%) - most common minor complication, Minor bleeding (0-1.2%) |
| Other Complications | Pneumothorax, Abscess formation, Bowel injury, Bile leak with or without peritonitis (rare) |
| Major Complications | Mortality (0-1.4%), Sepsis (0.9%) - managed by peri-procedure antibiotic management, Significant bleeding requiring transfusion, embolization or immediate laparotomy |