Percutaneous cholecystostomy is the image-guided placement of a drainage catheter into the gallbladder lumen. This minimally invasive procedure can aid in patient stabilization in order to enable a more measured surgical approach with time for therapeutic planning.
A 2018 study demonstrated no difference in mortality between percutaneous cholecystostomy and laparoscopic cholecystectomy in high-risk patients with acute calculous cholecystitis, however, laparoscopic cholecystectomy had a significantly lower complication rate than percutaneous cholecystostomy 11.
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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 the 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 track 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
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 routes 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 institutional 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 a supine position
regular monitoring of the vital signs by a suitably trained staff member is recommended during the procedure
clean skin with an 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 anesthesia typically with 1% lidocaine
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trocar technique:
8-10 French locking pigtail catheter with trocar (thick or purulent bile may require catheter >8 Fr)
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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 a preparatory solution
place a sterile drape to isolate the sterile field
apply 1% lidocaine local anesthetic; anesthetize the liver capsule when using a transhepatic route
make skin "nick" with #11 blade
insert catheter using trocar or Seldinger technique
secure catheter to the skin (commercial fixation system could be used)
attach the gravity drainage bag to the 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 visualized under ultrasound. Aspiration of bile/pus from the drain confirms satisfactory position.
Also see main article: Seldinger technique
Trocar technique
Load 8 French locking pigtail catheter over trocar. Advance the catheter assembly into the gallbladder lumen by sonographic guidance; it is possible to visualize tip in the gallbladder lumen. Aspiration of bile/pus from the drain confirms a satisfactory position. Unscrew trocar from catheter; advance catheter over 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 for 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 the 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
