Cholecystostomy

Last updated
Cholecystostomy
Specialty General Surgery, Gastroenterology
ICD-10-PCS ICD-10-PCS 0F9430Z
ICD-9-CM 51.02, 51.03
MeSH D002767

Cholecystostomy or (cholecystotomy) is a medical procedure used to drain the gallbladder through either a percutaneous or endoscopic approach. The procedure involves creating a stoma in the gallbladder, which can facilitate placement of a tube or stent for drainage, first performed by American surgeon, Dr. John Stough Bobbs, in 1867. [1] [2] [3] It is sometimes used in cases of cholecystitis or other gallbladder disease where the person is ill, and there is a need to delay or defer cholecystectomy. [4] The first endoscopic cholecystostomy was performed by Drs. Todd Baron and Mark Topazian in 2007 using ultrasound guidance to puncture the stomach wall and place a plastic biliary catheter for gallbladder drainage. [5]

Contents

Indications

Cholecystostomy finds its application when the patient has cholecystitis and is not a good candidate for surgery. [6] Some indications include:

Contraindications

Contraindications to cholecystostomy include:

Percutaneous cholecystostomy

Approach

Percutaneous cholecystostomy is performed under general anesthesia and guided by ultrasound (US) or computed tomography (CT) imaging. [7] There are 3 major considerations when deciding the approach for this procedure.

  1. Trans-hepatic. This approach is most common and involves puncturing through the liver into the gallbladder. [8] Some advantages include: fewer bile leaks due to the liver abutting against the gallbladder and acting as a tamponade, lower risk of bowel perforation, and better outcomes in patients with severe ascites. [8] The major disadvantage is the increased risk of liver hemorrhage, especially in patients with coagulation disorders. [8]
  2. Trans-peritoneal. This approach is used when anatomical challenges or liver diseases and coagulopathy prevent the trans-hepatic approach. [7] It involves avoiding the liver and going through the peritoneal cavity. The primary advantage is decreased risk of liver hemorrhage. The major disadvantage is increased incidence of bile leaks. [8]
  3. Subcostal vs. Intercostal. The literature currently does not have enough evidence to support one approach over the other. However, it is believed that due to the proximity to the lung and the associated neurovascular bundle under the ribs, the intercostal approach may be associated with higher incidence of pneumothorax, pleurobiliary fistula, and nerve damage. Thus, the subcostal approach is preferred. [8]

There are numerous studies comparing the trans-hepatic and trans-peritoneal approaches and their associated complications. Some studies have shown that there is no statistically significant difference in complications between the two approaches and recommend operator preference. A more recent study, however, did suggest greater incidence of hemorrhage with the trans-hepatic approach. [8]

Technique

Before the procedure, a thorough review of the patient's imaging is conducted to evaluate the anatomy of the gallbladder and surrounding structures. [9] The patient's clinical status, medications, and laboratory values (i.e. white blood cell count, coagulation studies, inflammatory markers, anticoagulation therapy, etc.) are reviewed to ensure the patient is stable for the procedure. [9]

Once the patient is ready, the surgical site is cleaned with an antiseptic solution to minimize the risk of infection. [9] Local anesthesia, in the form of a topical 1% lidocaine injection, is administered. A small incision is made in the right upper quadrant (RUQ) directly above the gallbladder, using a #11 blade. [9] At this point, there are 2 main techniques to perform the cholecystostomy.

  1. Seldinger technique. The Seldinger technique starts with inserting an 18 or 19-gauge needle with a guide wire through the incision into the gallbladder under image guidance. [9] The needle is then removed and exchanged with progressively larger dilators to enlarge the opening into the gallbladder. Finally, an 8 French pigtail catheter or larger (if indicated) is inserted over the guide wire. Once the pigtail is visualized to be securely lodged into the gallbladder, the guide wire is removed and a gravity drain is attached to the catheter. The Seldinger technique allows for a smaller needle size, which decreases perforation risk. [9]
  2. Trocar technique. The Trocar technique starts with loading an 8 french pigtail catheter over a trocar. Under image guidance, the apparatus is inserted until the tip is visualized entering the gallbladder. The pigtail catheter is then inserted over the trocar into the gallbladder. Once the catheter is in place, it is locked and the trocar is removed. Finally, a gravity drain is attached to drain fluid from the gallbladder. [9]

Complications

Cholecystostomy is a medical procedure and carries its share of complications and adverse effects. Complications occur in approximately 10% of cases. [7] The most common issues encountered are catheter dislodgement, blockage, or a bile leak, which, while frequent, are considered minor complications. [10] Major complications, although rare, encompass sepsis, significant hemorrhage, pneumothorax, and bowel injury. [10] Notably, the transhepatic approach offers advantages by reducing the risk of both organ perforation and bile leaks. [10]

Tube Removal

Once the cholecystostomy tube is placed, it is recommended to keep the tube for 3–6 weeks to allow the tract to mature. [11] Studies have shown that premature removal (before 21 days) is associated with a higher incidence of bile leaks. [11] Once the cholecystitis is resolved and adequate time has passed for tract maturation, a clamp trial can be conducted for 24 hours to assess drainage from the gallbladder. [9] If the patient passes the clamp trial (minimal to no drainage after unclamping), the tube is removed. Future management consists of performing a cholecystectomy to prevent future episodes of cholecystitis once the patient is stable for surgery. [9]

Endoscopic cholecystostomy

An alternative to the percutaneous cholecystostomy is to use the endoscopic route. There are 2 primary techniques: endoscopic transpapillary gallbladder drainage (ET-GBD) and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD). These techniques are considered when the patient is a poor candidate for surgical cholecystectomy but can tolerate anesthesia for an endoscopic procedure and does not have a gallbladder perforation. [3]

Endoscopic Transpapillary Gallbladder Drainage

This procedure is performed during an endoscopic retrograde cholangiopancreatography (ERCP). The cystic duct is cannulated and a plastic stent is deployed to relieve the blockage and allow for drainage. ET-GBD can be considered when the patient is already undergoing an ERCP for another medical condition (i.e. choledocholithiasis). Some drawbacks include an increased risk of pancreatitis from the ERCP procedure and a lower success rate compared to EUS-GBD or percutaneous cholecystostomy, particularly when there is evidence of cystic duct obstruction (i.e. stones, adhesions, strictures, cancer, or other masses). [3]

Endoscopic Ultrasound-guided Gallbladder Drainage

EUS-GBD allows for internal drainage by placing a lumen-apposing metal stent (LAMS) into the gallbladder from either the stomach or the duodenum.  The procedure involves using a cautery-powered LAMS to puncture through the gastric wall and enter the gallbladder. Two flanges on either side of the LAMS are deployed, tethering the stent on the inside walls of the gallbladder and gastric lumen. An important consideration is that the gallbladder must be within 10mm of the gastric puncture site. EUS-GBD is a good option for patients who are unlikely to undergo a future surgical cholecystectomy. It may also be used in patients with a cystic duct occlusion, or a pre-existing uncovered metal biliary stent. Some advantages include a high success rate with few complications and a reduced need for reinterventions. The primary drawback is the risk of stent occlusion with food or gastric contents. This risk is lowered when entering through the duodenum. EUS-GBD also complicates a future surgical cholecystectomy because the patient's anatomy is modified, requiring an additional repair of the choleycystoenteric fistula. [3]

See also

Related Research Articles

<span class="mw-page-title-main">Gallbladder</span> Organ in humans and other vertebrates

In vertebrates, the gallbladder, also known as the cholecyst, is a small hollow organ where bile is stored and concentrated before it is released into the small intestine. In humans, the pear-shaped gallbladder lies beneath the liver, although the structure and position of the gallbladder can vary significantly among animal species. It receives and stores bile, produced by the liver, via the common hepatic duct, and releases it via the common bile duct into the duodenum, where the bile helps in the digestion of fats.

<span class="mw-page-title-main">Bile duct</span> Type of organ

A bile duct is any of a number of long tube-like structures that carry bile, and is present in most vertebrates.

<span class="mw-page-title-main">Gallstone</span> Disease where stones form in the gallbladder

A gallstone is a stone formed within the gallbladder from precipitated bile components. The term cholelithiasis may refer to the presence of gallstones or to any disease caused by gallstones, and choledocholithiasis refers to the presence of migrated gallstones within bile ducts.

<span class="mw-page-title-main">Cholecystitis</span> Inflammation of the gallbladder

Cholecystitis is inflammation of the gallbladder. Symptoms include right upper abdominal pain, pain in the right shoulder, nausea, vomiting, and occasionally fever. Often gallbladder attacks precede acute cholecystitis. The pain lasts longer in cholecystitis than in a typical gallbladder attack. Without appropriate treatment, recurrent episodes of cholecystitis are common. Complications of acute cholecystitis include gallstone pancreatitis, common bile duct stones, or inflammation of the common bile duct.

<span class="mw-page-title-main">Interventional radiology</span> Medical subspecialty

Interventional radiology (IR) is a medical specialty that performs various minimally-invasive procedures using medical imaging guidance, such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound. IR performs both diagnostic and therapeutic procedures through very small incisions or body orifices. Diagnostic IR procedures are those intended to help make a diagnosis or guide further medical treatment, and include image-guided biopsy of a tumor or injection of an imaging contrast agent into a hollow structure, such as a blood vessel or a duct. By contrast, therapeutic IR procedures provide direct treatment—they include catheter-based medicine delivery, medical device placement, and angioplasty of narrowed structures.

<span class="mw-page-title-main">Cholecystectomy</span> Surgical removal of the gallbladder

Cholecystectomy is the surgical removal of the gallbladder. Cholecystectomy is a common treatment of symptomatic gallstones and other gallbladder conditions. In 2011, cholecystectomy was the eighth most common operating room procedure performed in hospitals in the United States. Cholecystectomy can be performed either laparoscopically, or via an open surgical technique.

<span class="mw-page-title-main">Endoscopic retrograde cholangiopancreatography</span> Use of endoscopy and fluoroscopy to treat and diagnose digestive issues.

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. It is primarily performed by highly skilled and specialty trained gastroenterologists. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject a contrast medium into the ducts in the biliary tree and pancreas so they can be seen on radiographs.

Mirizzi's syndrome is a rare complication in which a gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the common hepatic duct, resulting in obstruction and jaundice. The obstructive jaundice can be caused by direct extrinsic compression by the stone or from fibrosis caused by chronic cholecystitis (inflammation). A cholecystocholedochal fistula can occur.

<span class="mw-page-title-main">Common bile duct stone</span> Medical condition

Common bile duct stone, also known as choledocholithiasis, is the presence of gallstones in the common bile duct (CBD). This condition can cause jaundice and liver cell damage. Treatments include choledocholithotomy and endoscopic retrograde cholangiopancreatography (ERCP).

<span class="mw-page-title-main">Gallbladder cancer</span> Medical condition

Gallbladder cancer is a relatively uncommon cancer, with an incidence of fewer than 2 cases per 100,000 people per year in the United States. It is particularly common in central and South America, central and eastern Europe, Japan and northern India; it is also common in certain ethnic groups e.g. Native American Indians and Hispanics. If it is diagnosed early enough, it can be cured by removing the gallbladder, part of the liver and associated lymph nodes. Most often it is found after symptoms such as abdominal pain, jaundice and vomiting occur, and it has spread to other organs such as the liver.

An accessory bile duct is a conduit that transports bile and is considered to be supernumerary or auxiliary to the biliary tree.

<span class="mw-page-title-main">Biliary fistula</span> Medical condition

A biliary fistula is a type of fistula in which bile flows along an abnormal connection from the bile ducts into a nearby hollow structure. Types of biliary fistula include:

<span class="mw-page-title-main">Ascending cholangitis</span> Medical condition

Ascending cholangitis, also known as acute cholangitis or simply cholangitis, is inflammation of the bile duct, usually caused by bacteria ascending from its junction with the duodenum. It tends to occur if the bile duct is already partially obstructed by gallstones.

<span class="mw-page-title-main">Biliary colic</span> Medical condition in which gallstones cause acute pain

Biliary colic, also known as symptomatic cholelithiasis, a gallbladder attack or gallstone attack, is when a colic occurs due to a gallstone temporarily blocking the cystic duct. Typically, the pain is in the right upper part of the abdomen, and can be severe. Pain usually lasts from 15 minutes to a few hours. Often, it occurs after eating a heavy meal, or during the night. Repeated attacks are common. Cholecystokinin - a gastrointestinal hormone - plays a role in the colic, as following the consumption of fatty meals, the hormone triggers the gallbladder to contract, which may expel stones into the duct and temporarily block it until being successfully passed.

<span class="mw-page-title-main">Percutaneous transhepatic cholangiography</span> Medical imaging of the biliary tract

Percutaneous transhepatic cholangiography, percutaneous hepatic cholangiogram (PTHC) is a radiological technique used to visualize the anatomy of the biliary tract. A contrast medium is injected into a bile duct in the liver, after which X-rays are taken. It allows access to the biliary tree in cases where endoscopic retrograde cholangiopancreatography has been unsuccessful. Initially reported in 1937, the procedure became popular in 1952.

<span class="mw-page-title-main">Biliary sludge</span> Medical condition

Biliary sludge refers to a viscous mixture of small particles derived from bile. These sediments consist of cholesterol crystals, calcium salts, calcium bilirubinate, mucin, and other materials.

<span class="mw-page-title-main">Michel Kahaleh</span>

Michel Kahaleh is an American gastroenterologist and an expert in therapeutic endoscopy.

<span class="mw-page-title-main">Biloma</span> Circumscribed abdominal collection of bile outside the biliary tree

A biloma is a circumscribed abdominal collection of bile outside the biliary tree. It occurs when there is excess bile in the abdominal cavity. It can occur during or after a bile leak. There is an increased chance of a person developing biloma after having a gallbladder removal surgery, known as laparoscopic cholecystectomy. This procedure can be complicated by biloma with incidence of 0.3–2%. Other causes are liver biopsy, abdominal trauma, and, rarely, spontaneous perforation. The formation of biloma does not occur frequently. Biliary fistulas are also caused by injury to the bile duct and can result in the formation of bile leaks. Biliary fistulas are abnormal communications between organs and the biliary tract. Once diagnosed, they usually require drainage. The term "biloma" was first coined in 1979 by Gould and Patel. They discovered it in a case with extrahepatic bile leakage. The cause of this was trauma to the upper right quadrant of the abdomen. Originally, biloma was described as an "encapsulated collection" of extrahepatic bile. Biloma is now described as extrabiliary collections of bile that can be either intrahepatic or extrahepatic. The most common cause of biloma is trauma to the liver. There are other causes such as abdominal surgery, endoscopic surgery and percutaneous catheter drainage. Injury and abdominal trauma can cause damage to the biliary tree. The biliary tree is a system of vessels that direct secreations from the liver, gallbladder, and pancreas through a series of ducts into the duodenum. This can result in a bile leak which is a common cause of the formation of biloma. It is possible for biloma to be associated with mortality, though it is not common. Bile leaks occur in about one percent of causes.

<span class="mw-page-title-main">Choledochoduodenostomy</span>

Choledochoduodenostomy (CDD) is a surgical procedure to create an anastomosis, a surgical connection, between the common bile duct (CBD) and an alternative portion of the duodenum. In healthy individuals, the CBD meets the pancreatic duct at the ampulla of Vater, which drains via the major duodenal papilla to the second part of duodenum. In cases of benign conditions such as narrowing of the distal CBD or recurrent CBD stones, performing a CDD provides the diseased patient with CBD drainage and decompression. A side-to-side anastomosis is usually performed.

<span class="mw-page-title-main">Biliary endoscopic sphincterotomy</span> Use of endoscopy and fluoroscopy to treat and diagnose digestive issues.

Biliary endoscopic sphincterotomy is a procedure where the sphincter of Oddi and the segment of the common bile duct where it enters the duodenum are cannulated and then cut with a sphincterotome, a device that includes a wire which cuts with an electric current (electrocautery).

References

  1. ↑ Kelly, Howard A.; Burrage, Walter L. (eds.). "Bobbs, John Stough"  . American Medical Biographies  . Baltimore: The Norman, Remington Company.
  2. ↑ Bulletin of the Johns Hopkins Hospital, Vol. 12. Baltimore: The Johns Hopkins Press. Aug 1901. p. 249.
  3. 1 2 3 4 Irani, Shayan S.; Sharzehi, Kaveh; Siddiqui, Uzma D. (May 2023). "AGA Clinical Practice Update on Role of EUS-Guided Gallbladder Drainage in Acute Cholecystitis: Commentary". Clinical Gastroenterology and Hepatology. 21 (5): 1141–1147. doi:10.1016/j.cgh.2022.12.039. ISSN   1542-3565.
  4. ↑ Bakkaloglu H, Yanar H, Guloglu R, et al. (November 2006). "Ultrasound guided percutaneous cholecystostomy in high-risk patients for surgical intervention". World J. Gastroenterol. 12 (44): 7179–82. doi: 10.3748/wjg.v12.i44.7179 . PMC   4087782 . PMID   17131483.
  5. ↑ Baron TH, Topazian MD, et al. (April 2007). "Endoscopic transduodenal drainage of the gallbladder: implications for endoluminal treatment of gallbladder disease". Gastrointest. Endosc. 65 (4): 735–7. doi:10.1016/j.gie.2006.07.041. PMID   17141230.
  6. 1 2 3 4 5 6 7 Baron, Todd H.; Grimm, Ian S.; Swanstrom, Lee L. (2015-07-23). Campion, Edward W. (ed.). "Interventional Approaches to Gallbladder Disease". New England Journal of Medicine. 373 (4): 357–365. doi:10.1056/NEJMra1411372. ISSN   0028-4793.
  7. 1 2 3 4 5 6 Venara, A.; Carretier, V.; Lebigot, J.; Lermite, E. (2014-12-01). "Technique and indications of percutaneous cholecystostomy in the management of cholecystitis in 2014". Journal of Visceral Surgery. 151 (6): 435–439. doi:10.1016/j.jviscsurg.2014.06.003. ISSN   1878-7886.
  8. 1 2 3 4 5 6 Arkoudis, Nikolaos-Achilleas; Moschovaki-Zeiger, Ornella; Reppas, Lazaros; Grigoriadis, Stavros; Alexopoulou, Efthymia; Brountzos, Elias; Kelekis, Nikolaos; Spiliopoulos, Stavros (2023-10-01). "Percutaneous cholecystostomy: techniques and applications". Abdominal Radiology. 48 (10): 3229–3242. doi:10.1007/s00261-023-03982-2. ISSN   2366-0058.
  9. 1 2 3 4 5 6 7 8 9 Bashir, Omar. "Percutaneous cholecystostomy | Radiology Reference Article | Radiopaedia.org". Radiopaedia. Retrieved 2023-11-13.
  10. 1 2 3 Karakas, Hakki (2021). "Percutaneous Cholecystostomy: An Update for the 2020s". Northern Clinics of Istanbul. doi:10.14744/nci.2021.81594. PMC   8630714 . PMID   34909596.
  11. 1 2 Wise, James N.; Gervais, Debra A.; Akman, Andrew; Harisinghani, Mukesh; Hahn, Peter F.; Mueller, Peter R. (May 2005). "Percutaneous Cholecystostomy Catheter Removal and Incidence of Clinically Significant Bile Leaks: A Clinical Approach to Catheter Management". American Journal of Roentgenology. 184 (5): 1647–1651. doi:10.2214/ajr.184.5.01841647. ISSN   0361-803X.
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