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Percutaneous cholecystostomy

Percutaneous cholecystostomy is a image-guided placement of drainage catheter into gallbladder lumen8. This minimally invasive procedure can aid stabilization of a patient to enable a more measured surgical approach with time for therapeutic planning.4 

Indications

  • poor surgical candidate/high risk patients with acute calculous or acalculous cholecystitis.3
  • unexplained sepsis in critically ill patients (Diagnostic for cholecystitis as etiology of sepsis if clinical improvement after cholecystostomy).
  • access to or drainage of biliary tree following failed ERCP and PTC.

Contraindications

Absolute contraindications
  • usually none
Relative contraindications
  • bleeding diasthesis: all attempts should be made to correct coagulopathy.
  • ascites
  • gallbladder tumor that might be seeded
  • gallbladder packed with calculi preventing catheter insertion

Procedure

Preprocedural evaluation
  • review all available imaging to confirm the indication for the procedure. Previous imaging studies help to assess gallbladder anatomy and plan safe access route to the gallbladder.
  • check full blood count and coagulation profile to assess the risk of haemorrhage
  • obtain informed consent for the procedure
  • obtain good peripheral IV access
  • administer broad-spectrum IV antibiotics 1 - 4 hours prior to the procedure. Septic patients are often already on parenteral antibiotics.
  • arrange analgesia and sedation arranged according to patient confort and institution protocols. 
Laboratory parameters for a safe procedure

There are widely divergent opinions about the safe values of these indices for percutaneous procedures. The values ​​suggested below were considered based on the literature review, whose references are cited below.

Complete blood count : Platelet > 50000/mm3  (Some institutions determine other values between 50000 -100000/mm3)6;8

Coagulation profile: Some studies showed that having a normal INR or prothrombin time is no reassurance that the patient will not bleed after the procedure7.

  • international normalized ratio (INR) ≤ 1.5 8
  • normal prothrombin time (PT), partial thromboplastin time (PTT)
Positioning / room set up

The procedure is performed with the patient in supine position. Regular monitoring of the vital signs by a suitably trained staff member is recommended during the procedure. Clean skin with antiseptic solution and drape to maintain sterility for the procedure.

Equipment list

This procedure is often performed using ultrasound guidance, which was chosen to describe the procedure on this article. Alternatively modalities such as fluoroscopy or CT can also be used depending on the clinical situation, availability and local expertise.

  • ultrasound machine 
  • sterile ultrasound probe cover and sterile ultrasound gel
  • local anaesthesia typically with 1% lidocaine
  • Trocar technique:
    • 8-10 French locking pigtail catheter with trocar (thick or purulent bile may require catheter > 8 Fr)
  • Seldinger technique:
    • 18-gauge needle
    • 0.035" guidewire with 3 mm J-tip
    • 7-9 French dilator
    • 8-10 French locking pigtail catheter
Technique
  • clean skin with preparatory solution
  • place sterile drape to isolate sterile field
  • apply 1% lidocaine local anesthetic. Anesthetize liver capsule when using a transhepatic route. 
  • make skin "nick" with #11 blade
  • insert catheter using trocar or Seldinger technique
  • secure catheter to skin (commercial fixation system could be used). 
  • attach gravity drainage bag to catheter. 
  • send bile for gram stain, culture and/or cell count.

Seldinger technique -The gallbladder is punctured with an 18 or 19 gauge needle under ultrasound guidance. Bile can then be aspirated for microbiological studies. A 0.035 guidewire is used to exchange the needle for a dilator and an 8 French or larger pigtail drain is placed within the gallbladder. The drain can often be visualised under ultrasound. Aspiration of bile/pus from the drain confirms satisfactory position. 

Trocar technique -Load 8 French locking pigtail catheter over trocar. Advance the catheter assembly into GB lumen by sonographic guidance, it`s possible to visualize tip in gallbladder lumen. Aspiration of bile/pus from the drain confirms satisfactory position.  Unscrew trocar from catheter; advance catheter off of trocar into gallbladder, then remove trocar and lock pigtail. 

Postprocedural care

Bed rest (typically 2-4 hours) with regular monitoring vital signs, provision of adequate analgesia are routinely indicated in the first few hours following the procedure. Catheter is flushed and aspirated regularly with saline (6 to 8 hourly). A cholecystogram (injection of contrast into the indwelling catheter under fluoroscopy), performed when the patient is stable, helps establish satisfactory catheter position and the state of the gallbladder. It also allows assessment of any residual calculi in the biliary tree. The catheter can be removed once the tract is mature (usually 3-4 weeks). A trial of clamping the catheter for 24 hours is usually done prior to removing the catheter

Complications

  • bile leakage and biliary peritonitis
  • bleeding
  • bowel injury (transperitoneal puncture)
  • bradycardia and hypotension from gallbladder manipulation
  • catheter displacement/migration (commonest)

See also

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