Percutaneous cholecystostomy plays a key role in managing critical biliary tract complications. This method, preferred for patients with high surgical risk, has been used since the 1980s. In recent years, research has introduced technical innovations that enhance the safety and efficacy of the method. It is of vital importance in acute biliary conditions, particularly in cases of cholecystitis and cholangitis. Furthermore, technical success rates are very high and complications are generally mild.
| What You Need to Know About Percutaneous Cholecystostomy | |
| Definition | The procedure of providing drainage by placing a catheter into the gallbladder through the skin. |
| Indications | Acute cholecystitis, patients with high surgical risk, situations requiring urgent gallbladder drainage. |
| Contraindications | Bleeding disorders, infected or malignant gallbladder, anatomically unsafe conditions. |
| Pre‑procedure Preparation | Blood tests, targeting with ultrasound or CT, infection control, bleeding risk assessment, fasting requirements before the procedure. |
| Procedure Duration | Usually 30–60 minutes. |
| Anesthesia Type | Local anesthesia and sedation. |
| Procedure Steps | 1. Identification of the target area with ultrasound or CT 2. Administration of local anesthesia 3. Puncture of the skin and subcutaneous tissues 4. Placement of the catheter into the gallbladder 5. Verification and fixation of the catheter in the correct position |
| Complications | Infection, bleeding, bile leakage, catheter occlusion or migration, injury to surrounding organs. |
| Recovery Time | Usually a few days; the duration the catheter remains in place depends on the patient’s condition. |
| Success Rate | High; rapid resolution of acute cholecystitis symptoms. |
| Alternative Treatments | Laparoscopic or open cholecystectomy, conservative treatment (antibiotics, fluid therapy). |
Interventional Radiology / Interventional Neuroradiology
Prof. Dr. Özgür KILIÇKESMEZ
Indications for Percutaneous Cholecystostomy
Percutaneous cholecystostomy is used to manage critical gallbladder conditions. According to the 2010 practice guidelines from the Interventional Radiology Society, the primary applications of this procedure have been defined. Primarily, this method is very effective in the treatment of cholecystitis and in the removal of gallstones. The procedure provides direct access to the gallbladder to address these conditions.
In addition, percutaneous cholecystostomy has other important applications:
- Decompressing the biliary tract,
- Dilatation of biliary strictures,
- Stenting of malignant lesions.
These applications are considered as second‑line biliary access options in situations where direct intrahepatic biliary access is not possible. Each indication demonstrates the flexibility and versatility of the procedure.
Innovative Approaches in Acute Cholecystitis Treatment with Percutaneous Cholecystostomy
Acute cholecystitis is the inflammation of the gallbladder and is classified into two main types: acute calculous and acute acalculous cholecystitis. Both forms can lead to serious health problems. Acute calculous cholecystitis is most often caused by gallstones blocking the cystic duct, leading to inflammation. In contrast, acute acalculous cholecystitis occurs without gallstones and is generally associated with severe systemic illnesses.
- Gallstones account for 90% of acute calculous cholecystitis cases.
- Acalculous cholecystitis is typically seen in patients with severe underlying conditions.
The gender distribution in acute calculous cholecystitis shows that women constitute about 60% of cases, and cases in men tend to be more severe. The pathogenesis is usually characterized by impaction of a gallstone in the gallbladder or cystic duct. Initially sterile inflammation often becomes complicated by bacterial infection, most commonly involving Escherichia coli, Klebsiella, and Enterococcus species.
Furthermore, infection of the gallbladder wall by gas-forming organisms can result in emphysematous cholecystitis. If left untreated, this condition can progress to perforation of the gallbladder wall. In perforated cholecystitis, mortality rates range between 12% and 16%. The diagnosis of these conditions is typically made using imaging modalities, and cholecystectomy is considered the most effective treatment. However, in critically ill patients, this option may not always be feasible.
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Percutaneous Approaches in the Management of Acute Cholangitis
Acute cholangitis is a serious infection of the biliary tree that requires various treatment methods. The 2013 revised Tokyo Guidelines recommend minimally invasive endoscopic methods. However, in some cases endoscopic interventions may not be possible. In such cases, percutaneous transhepatic cholangial drainage (PTCD) serves as a second‑line treatment. The following situations may preclude endoscopic approaches:
- Absence of the papilla,
- Access difficulties due to previous gastrointestinal surgeries,
- Upper gastrointestinal system obstructions,
- Inability to pass the endoscope.
In addition, PTCD is an appropriate alternative in specific cases such as intrahepatic bile duct stones or peripheral obstructions. If an experienced endoscopist is unavailable or endoscopic intervention fails, PTCD is recommended. The procedure is generally performed via a transhepatic approach, although in some cases a transcholecystic approach may be considered. These procedures are vital in the management of acute cholangitis and are tailored to the patient’s condition.
Alternative Access Routes to the Biliary Tree
Transcystic access is emerging as an alternative method for accessing the biliary tree, particularly when transhepatic or endoscopic access is not feasible. For example, benign conditions such as malignancies or non-dilated intrahepatic bile ducts may necessitate this alternative approach. Once access is achieved, various therapeutic procedures can be performed for obstructive biliary conditions:
- Biliary stenting,
- Stone extraction.
This procedure is especially important for patients with biliary strictures. Percutaneous transcholecystic common bile duct stenting can be used when endoscopic or other percutaneous methods are not feasible. When the intrahepatic biliary tree cannot be clearly visualized with ultrasound, this method is employed. One study noted that when other methods were unsuitable, transcystic stenting achieved a 100% technical success rate. This process involves:
- Transhepatic approach via cystic access,
- Access to the bile duct using a guidewire,
- Placement of a metallic stent at the stricture segment.
Relative Contraindications for Percutaneous Cholecystostomy
There are no absolute contraindications for percutaneous cholecystostomy; however, certain conditions are considered relative contraindications. The most common among these is coagulopathy. In cases of coagulopathy, platelet and plasma transfusions should be administered pre‑procedure to correct blood values:
- Platelet count should exceed 50,000,
- International normalized ratio (INR) should be less than 1.5.
Patients with an allergy to iodinated contrast can undergo the procedure under ultrasound guidance instead of fluoroscopy. Additionally, in patients with ascites, paracentesis may be performed prior to biliary intervention. Recent studies have shown that the complication rates following transhepatic PC tube placement are low and comparable between patients with and without ascites. In cases with gallbladder stones, safe placement of the drainage catheter may be challenging. These contraindications are taken into account when determining the most appropriate treatment method for the patient.
Pre‑procedure Preparations for Percutaneous Cholecystostomy
There are important preparatory steps that must be carefully followed before performing percutaneous cholecystostomy. The patient’s coagulation status must be meticulously checked and corrected if abnormalities are present. Prophylactic antibiotic therapy is usually started 12 to 24 hours before the procedure to reduce the risk of infection. Detailed cross‑sectional imaging with MR and CT scans is crucial for a clear understanding of the patient’s anatomy, which helps minimize risks during the procedure.
Key pre‑procedure steps include:
- Assessment and correction of coagulation profile,
- Administration of prophylactic antibiotics,
- Detailed anatomical evaluation using MR and CT scans.
Ultrasound is critical for assessing the condition of the gallbladder wall and identifying adjacent bowel structures that might affect the procedure. These findings also guide the determination of access routes. The transhepatic approach, which passes through the liver parenchyma, increases catheter stability. This method also offers the advantage of reducing bile leakage and providing a faster recovery. Alternatively, a transperitoneal approach is preferred in patients with widespread liver disease, as it reduces the risk of bleeding and fistula formation.
Methods and Applications of Percutaneous Cholecystostomy
Percutaneous cholecystostomy is a radiologically guided procedure. Accurate imaging of the anatomy during the procedure is of vital importance. Ultrasound is most commonly used because its portability and real‑time imaging capabilities provide significant advantages. When the patient’s condition allows, high‑resolution images may also be obtained with computed tomography (CT). However, compared to ultrasound, CT can be more cumbersome, so it is used when visualization of the gallbladder is challenging with ultrasound.
The procedure is generally performed in the following steps:
- Sedation: The patient is usually sedated intravenously with midazolam and fentanyl.
- Access Needle: An access needle ranging from 22 to 18 gauge is initially used.
- Verification of Needle Position: The correct position of the needle is confirmed by aspirating bile or by injecting contrast agent under fluoroscopic guidance.
- Drainage Catheter:
- An 8 or 10F drainage catheter with multiple side holes is used.
- The catheter is advanced over a guidewire into the gallbladder.
- After bile is drained, a sample is sent for culture and antibiotic sensitivity testing.
- The catheter is left in place for gravity drainage.
When fluoroscopy is used, a cholecystogram can be performed during the procedure, and subsequently, a cholangiogram is used to evaluate the catheter’s position and the patency of the cystic duct. At the end of the procedure, successful decompression of the gallbladder is confirmed. The Seldinger technique or trocar technique can be chosen based on the specific case. The Seldinger technique is used for serial dilation and placement of a drainage tube into the gallbladder, while the trocar technique is typically reserved for advanced interventions such as gallstone extraction or stent placement.
Outcomes and Associated Complications of Percutaneous Cholecystostomy
Technical success rates for percutaneous cholecystostomy (PC) are very high, ranging between 95% and 100%. Failures are usually due to thick bile aspiration or anatomically challenging access. Inability to access the gallbladder is often due to factors such as a decompressed gallbladder or calcification. Patients with high APACHE II and CCI scores may experience poorer outcomes after PC. Early intervention reduces complication rates and hospital stay.
Complications include:
Major Complications:
- Procedure‑related mortality: between 0% and 1.4%
- Sepsis and significant bleeding requiring transfusion
Minor Complications:
- Catheter dislodgement: between 4.5% and 15%
- Minor bleeding: between 0% and 1.2%
- Biliary infection and sepsis: usually pre‑existing, with an incidence of 0.9%
- Pneumothorax, abscess formation, bowel injury, and bile leakage
Pre‑procedure antibiotics help reduce the incidence of sepsis. Comorbidities can affect the risks and outcomes of the procedure, making careful patient selection and timely intervention essential for success.
Future Perspectives in Percutaneous Cholecystostomy
Percutaneous cholecystostomy is known for its significant advantages in the treatment of acute cholecystitis. It is considered a central component of treatment algorithms according to the Tokyo Guidelines. This method is also preferred for its safety, given its high clinical and technical success rates. The low complication rate is a major factor in its widespread adoption. Currently, the ongoing CHOCOLATE trial aims to provide further scientific evidence on the efficacy of this treatment. With advancing technology:
- Its use in treating both malignant and benign strictures,
- A wide range of biliary conditions up to gallstone extraction is being explored.
These advances continue to reshape the role of percutaneous cholecystostomy in managing biliary pathologies, ensuring that this procedure remains central both in acute management and in long-term treatment planning.
Additional Resources and Documents
https://ozgurkilickesmez.com/wp-content/uploads/2024/07/white-et-al-2022-carotid-artery-stenting.pdf
Prof. Dr. Özgür Kılıçkesmez graduated from Cerrahpaşa Medical Faculty in 1997. He completed his specialization at Istanbul Education and Research Hospital. He received training in interventional radiology and oncology in London. He founded the interventional radiology department at Istanbul Çam and Sakura City Hospital and became a professor in 2020. He holds many international awards and certificates, has over 150 scientific publications, and has been cited more than 1500 times. He is currently working at Medicana Ataköy Hospital.
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