Cholecystostomy Tube

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Overview

Percutaneous cholecystostomy tube is a common interventional radiology procedure that involves placing a drain into the gallbladder lumen. The most common indication is for drainage of the gallbladder in the setting of cholecystitis. Often patients are poor surgical candidates. The procedure can be performed using multiple modalities including fluoroscopy, ultrasound and/or CT. Many operators prefer the combination of US and fluoroscopy. Techniques for drain placement can vary between operators and between patients, but with a solid understanding of the basics of drain placement, this procedure can be accomplished safely. Understanding the indications and drain management following cholecystostomy tube placement often involve more expert training.

Pre-Procedure Prep

Indications

• Gallbladder decompression
• Access to biliary tract for intervention
• Cholecystitis is most common indication

Contraindications

• Few if any absolute contraindications
• Interposed colon or small bowel may preclude access
• Severe bleeding diathesis
• Gallbladder tumor and risk of seeding along tract
• Porcelain gallbladder or gallbladder completely filled with stones can make drain placement difficult
• Perforated gallbladder can make tube placement extremely difficult

SIR Periprocedural Coagulation Parameters

• INR, aPTT, platelets labs recommended
• INR: correct to < 1.9
• Platelets: < 50,000/µl recommend transfusion
• aPTT: correct so that value is < 1.5 control
Suggested laboratory parameters for patients with chronic liver disease
• INR < 2.5
• Platelets: > 30,000
• Consider fibrinogen level

Pre-Procedural Evaluation

• H&P
• Known indication for referral
• Evaluate patient comorbidities for procedure and anesthesia plan
• Medication review: antibiotics and anticoagulation
Imaging
• Signs of cholecystitis or cystic duct patency
• Cross-sectional helpful to evaluate access route and plan for adjacent critical structures

Cholecystostomy Tube Procedure Steps

Antibiotic

• 1 g ceftriaxone (Rocephin) IV
• Vancomycin or clindamycin-gentamicin for PCN allergy
Other regimens
• 1.5–3 g ampicillin/sulbactam (Unasyn) IV
• 1 g cefotetan IV plus 4 g mezlocillin IV
• 2 g ampicillin IV plus 1.5 mg/kg gentamicin IV

Approach

[1] Transhepatic
• Drain anchored within liver parenchyma improves drain stability
• Reduces risk of bile leak
• Faster tract maturation
• Higher risk of bleeding or liver injury when traversing liver parenchyma
• Often access site is higher which increased risk of lung/pleural transgression
[2] Transperitoneal
• May be preferred route if planning for subsequent intervention such as lithotripsy
• Reduces risk of liver injury or hemorrhage
• Avoids diffuse liver disease or potential liver metastasis

Procedure

• Approach: transhepatic vs transperitoneal approach
• Access gallbladder with US guidance using 18-22 gauge needle
• Inject contrast to confirm position with option for cholecystogram to evaluate cystic duct
• If 20 gauge needle or smaller, will need to place 0.018" wire
• Accustick or Neff set to transition to 0.035" wire
• Serial dilate
• Place 8 or 10 Fr pigtail drain
• Obtain bile for cultures
• Attach drain to gravity bag

Post-Procedure

Post-Procedural Care

• Bed rest for 2-4 hours
• Continue antibiotics for at least 48 hours
• Flush catheter at least once per day with 10 mL normal saline
• Record drain output

Complications

• Tube displacement or dislodgement: 4.5-13.2% (most common)
• Bile leak or peritonitis: 1.9-2.4%
• Bleeding requiring transfusion: < 2%
• Sepsis: < 1%
• Procedure-related mortality: 0-1.4%

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Join The Discussion

References

[1] Patel IJ, Rahim S, Davidson JC, et al. Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions-Part II: Recommendations: Endorsed by the Canadian Association for Interventional Radiology and the Cardiovascular and Interventional Radiological Society of Europe. J Vasc Interv Radiol. 2019;30(8):1168-1184.e1. doi:10.1016/j.jvir.2019.04.017
[2] Chehab MA, Thakor AS, Tulin-Silver S, et al. Adult and Pediatric Antibiotic Prophylaxis during Vascular and IR Procedures: A Society of Interventional Radiology Practice Parameter Update Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Association for Interventional Radiology. J Vasc Interv Radiol. 2018;29(11):1483-1501.e2. doi:10.1016/j.jvir.2018.06.007
[3] Ansaloni L, Pisano M, Coccolini F, et al. 2016 WSES guidelines on acute calculous cholecystitis [published correction appears in World J Emerg Surg. 2016 Nov 4;11:52]. World J Emerg Surg. 2016;11:25. Published 2016 Jun 14. doi:10.1186/s13017-016-0082-5
[4] Popowicz A, Lundell L, Gerber P, et al. Cholecystostomy as Bridge to Surgery and as Definitive Treatment or Acute Cholecystectomy in Patients with Acute Cholecystitis. Gastroenterol Res Pract. 2016;2016:3672416. doi:10.1155/2016/3672416
[5] Yeo CS, Tay VW, Low JK, Woon WW, Punamiya SJ, Shelat VG. Outcomes of percutaneous cholecystostomy and predictors of eventual cholecystectomy. J Hepatobiliary Pancreat Sci. 2016;23(1):65-73. doi:10.1002/jhbp.304
[6] Pang KW, Tan CH, Loh S, et al. Outcomes of Percutaneous Cholecystostomy for Acute Cholecystitis. World J Surg. 2016;40(11):2735-2744. doi:10.1007/s00268-016-3585-z
[7] Katabathina VS, Zafar AM, Suri R. Clinical Presentation, Imaging, and Management of Acute Cholecystitis. Tech Vasc Interv Radiol. 2015;18(4):256-265. doi:10.1053/j.tvir.2015.07.009
[8] Joseph T, Unver K, Hwang GL, et al. Percutaneous cholecystostomy for acute cholecystitis: ten-year experience. J Vasc Interv Radiol. 2012;23(1):83-8.e1. doi:10.1016/j.jvir.2011.09.030


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