Percutaneous cholecystostomy

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

Indications

• poor surgical candidate/high risk / high-risk patients with acute calculous or acalculous cholecystitis ³
• unexplained sepsis in critically ill patients (diagnostic for cholecystitis as aetiology 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 diathesis: all attempts should be made to correct coagulopathy
• ascites: thought to increase the risk of failed tract maturation but a 2015 study demonstrated this is not increased when compared to patients without ascites ¹⁰
• gallbladder tumour 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 satisfactory 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 comfort 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 >50,000/mm³ (Some institutions determine other values between 50,000-100,000/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 procedure ⁷.

• international normalised ratio (INR) ≤1.5 ⁸
• normal prothrombin time (PT), partial thromboplastin time (PTT)

Positioning and 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 in 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 the sterile field
• apply 1% lidocaine local anaesthetic; anaesthetise 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 gallbladder lumen by sonographic guidance, it is possible to visualise 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 of vital signs and 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.

Taking into account age and comorbidities, cholecystectomy after resolution of cholecystitis is normally performed in order to prevent recurrent cholecystitis. ⁹

Complications

• catheter displacement/migration (most common)
• bile leakage and biliary peritonitis (see: biloma)
• bleeding
• bowel injury (transperitoneal puncture)
• bradycardia and hypotension from gallbladder manipulation

See also

• percutaneous transhepatic cholangiography (PTC)
• other liver and biliary interventional procedures
• cholecystitis