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.
A 2018 study 11 demonstrate no difference in mortality between percutaneous cholecystostomy and laparoscopic cholecystectomy in high-risk patients with acute calculous cholecystectomy, however, laparoscopic cholecystectomy had a significantly lower complication rate than percutaneous cholecystostomy.
- 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
- usually none
- 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 tumor that might be seeded
- gallbladder packed with calculi preventing catheter insertion
- 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 hemorrhage
- 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 normalized 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.
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 anesthesia typically with 1% lidocaine
- trocar technique:
- 8-10 French locking pigtail catheter with trocar (thick or purulent bile may require catheter >8 Fr)
- 18-gauge needle
- 0.035" guidewire with 3 mm J-tip
- 7-9 French dilator
- 8-10 French locking pigtail catheter
- clean skin with preparatory solution
- place sterile drape to isolate the 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
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 visualized under ultrasound. Aspiration of bile/pus from the drain confirms satisfactory position.
Load 8 French locking pigtail catheter over trocar. Advance the catheter assembly into gallbladder lumen by sonographic guidance, it is 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.
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
- catheter displacement/migration (most common)
- bile leakage and biliary peritonitis (see: biloma)
- bowel injury (transperitoneal puncture)
- bradycardia and hypotension from gallbladder manipulation
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- 3. Huang CC, Lo HC, Tzeng YM et-al. Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department. Emerg Med J. 2007;24 (12): 836-40. doi:10.1136/emj.2007.052175 - Free text at pubmed - Pubmed citation
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- 6. Sue M, Caldwell SH, Dickson RC et-al. Variation between centers in technique and guidelines for liver biopsy. Liver. 1997;16 (4): 267-70. Pubmed citation
- 7. Gilmore IT, Burroughs A, Murray-Lyon IM et-al. Indications, methods, and outcomes of percutaneous liver biopsy in England and Wales: an audit by the British Society of Gastroenterology and the Royal College of Physicians of London. Gut. 1995;36 (3): 437-41. Free text at pubmed - Pubmed citation
- 8. Walker TG. Interventional Procedures. Lippincott Williams & Wilkins. (2012) ISBN:1931884862. Read it at Google Books - Find it at Amazon
- 9. Ha JP, Tsui KK, Tang CN et-al. Cholecystectomy or not after percutaneous cholecystostomy for acute calculous cholecystitis in high-risk patients. Hepatogastroenterology. 2009;55 (86-87): 1497-502. Pubmed citation
- 10. Duncan, C.T. et al. Outcomes of percutaneous cholecystostomy in the presence of ascites. Journal of Vascular and Interventional Radiology , Volume 26 , Issue 2 , S194
- 11. Loozen Charlotte S, van Santvoort Hjalmar C, van Duijvendijk Peter, Besselink Marc GH, Gouma Dirk J, Nieuwenhuijzen Grard AP et al. Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial BMJ 2018; 363 :k3965
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