User:Tacobellbeanburrito/Cholecystostomy

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Indications

Cholecystostomy finds its application when the patient is not a good candidate for surgery. Some indications include:

- Critically ill patients that are clinically unstable to tolerate surgical cholecystectomy

- Patients unable to tolerate anesthesia during the surgery

- Surgically high-risk patients with severe systemic disease (ASA Physical Status Level III)

- Patients resistant to medical management (no clinical improvement after at least 72hrs of medical treatment)

- Severe acute cholecystitis (Grade III acute cholecystitis according to the Tokyo Guidelines)

Contraindications

Contraindications to cholecystostomy include:

- Coagulopathy

- Interposition of gastrointestinal contents between the skin and the gallbladder (increases the risk of organ perforation)

- Biliary peritonitis

- Ascites

Technique:

Percutaneous cholecystostomy is performed under general anesthesia and guided by ultrasound (US) or computed tomography (CT) imaging. There are two primary routes for catheter placement: trans-hepatic, which is more common and reduces the risk of biliary leak, and trans-peritoneal, used when anatomical challenges or liver diseases and coagulopathy prevent the trans-hepatic approach.

Before the procedure, a thorough review of the patient's imaging is conducted to evaluate the anatomy of the gallbladder and surrounding structures. 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.

Once the patient is ready, the surgical site is cleaned with an antiseptic solution to minimize the risk of infection. 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. At this point, there are 2 main techniques to perform the cholecystostomy: Seldinger and Trochar techniques. 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. 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.

The Trochar 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 trochar into the gallbladder. Once the catheter is in place, it is locked and the trochar is removed. Finally, a gravity drain is attached to drain fluid from the gallbladder.

Complications

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

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. Studies have shown that premature removal (before 21 days) is associated with a higher incidence of bile leaks. 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. 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.