Cholecystostomy or (cholecystotomy) is a medical procedure used to drain the

gallbladder In vertebrates, the gallbladder, also known as the cholecyst, is a small hollow Organ (anatomy), organ where bile is stored and concentrated before it is released into the small intestine. In humans, the pear-shaped gallbladder lies beneath t ...

through either a percutaneous or endoscopic approach. The procedure involves creating a

stoma In botany, a stoma (: stomata, from Greek language, Greek ''στόμα'', "mouth"), also called a stomate (: stomates), is a pore found in the Epidermis (botany), epidermis of leaves, stems, and other organs, that controls the rate of gas exc ...

in the gallbladder, which can facilitate placement of a tube or stent for

drainage Drainage is the natural or artificial removal of a surface's water and sub-surface water from an area with excess water. The internal drainage of most agricultural soils can prevent severe waterlogging (anaerobic conditions that harm root gro ...

, first performed by American surgeon, Dr. John Stough Bobbs, in 1867. It is sometimes used in cases of

cholecystitis Cholecystitis is inflammation of the gallbladder. Symptoms include Right upper quadrant (abdomen), right upper abdominal pain, pain in the right shoulder, nausea, vomiting, and occasionally fever. Often gallbladder attacks (biliary colic) precede ...

or other gallbladder disease where the person is ill, and there is a need to delay or defer

cholecystectomy 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 i ...

. 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.

Indications

Cholecystostomy finds its application when the patient has cholecystitis and is not a good candidate for surgery. Some indications include: * Critically ill patients that are clinically unstable to tolerate surgical

* Patients unable to tolerate

anesthesia Anesthesia (American English) or anaesthesia (British English) is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prev ...

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 72 hours of medical treatment) * Severe acute cholecystitis (Grade III acute cholecystitis according to the Tokyo Guidelines)

Contraindications

Contraindications to cholecystostomy include: *

Coagulopathy Coagulopathy (also called a bleeding disorder) is a condition in which the blood's ability to coagulate (form clots) is impaired. This condition can cause a tendency toward prolonged or excessive bleeding ( bleeding diathesis), which may occur s ...

* Interposition of gastrointestinal contents between the skin and the gallbladder (increases the risk of organ

perforation A perforation is a small hole in a thin material or web. There is usually more than one perforation in an organized fashion, where all of the holes collectively are called a ''perforation''. The process of creating perforations is called perfor ...

) * Biliary

peritonitis Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and covering of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One pa ...

Ascites Ascites (; , meaning "bag" or "sac") is the abnormal build-up of fluid in the abdomen. Technically, it is more than 25 ml of fluid in the peritoneal cavity, although volumes greater than one liter may occur. Symptoms may include increased abdo ...

Percutaneous cholecystostomy

Approach

Percutaneous cholecystostomy is performed under sedation and guided by

ultrasound Ultrasound is sound with frequency, frequencies greater than 20 Hertz, kilohertz. This frequency is the approximate upper audible hearing range, limit of human hearing in healthy young adults. The physical principles of acoustic waves apply ...

(US) or

computed tomography A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...

(CT) imaging. There are 3 major considerations when deciding the approach for this procedure. # Trans-hepatic. This approach is most common and involves puncturing through the

liver The liver is a major metabolic organ (anatomy), organ exclusively found in vertebrates, which performs many essential biological Function (biology), functions such as detoxification of the organism, and the Protein biosynthesis, synthesis of var ...

into the gallbladder. 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 Ascites (; , meaning "bag" or "sac") is the abnormal build-up of fluid in the abdomen. Technically, it is more than 25 ml of fluid in the peritoneal cavity, although volumes greater than one liter may occur. Symptoms may include increased abdo ...

. The major disadvantage is the increased risk of liver

hemorrhage Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, ...

, especially in patients with coagulation disorders. # Trans-peritoneal. This approach is used when anatomical challenges or

liver diseases Hepato-biliary diseases include liver diseases and biliary diseases. Their study is known as hepatology. Liver diseases Viral hepatitis * Acute hepatitis A * Acute hepatitis B * Acute hepatitis C * Acute hepatitis D – this is a superinfecti ...

and coagulopathy prevent the trans-hepatic approach. It involves avoiding the liver and going through the

peritoneal The peritoneum is the serous membrane forming the lining of the abdominal cavity or coelom in amniotes and some invertebrates, such as annelids. It covers most of the intra-abdominal (or coelomic) organs, and is composed of a layer of mesotheli ...

cavity. The primary advantage is decreased risk of liver hemorrhage. The major disadvantage is increased incidence of bile leaks. # 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 The lungs are the primary Organ (biology), organs of the respiratory system in many animals, including humans. In mammals and most other tetrapods, two lungs are located near the Vertebral column, backbone on either side of the heart. Their ...

and the associated neurovascular bundle under the ribs, the intercostal approach may be associated with higher incidence of

pneumothorax A pneumothorax is collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and dyspnea, shortness of breath. In a minority of cases, a one-way valve is ...

, pleurobiliary

fistula In anatomy, a fistula (: fistulas or fistulae ; from Latin ''fistula'', "tube, pipe") is an abnormal connection (i.e. tube) joining two hollow spaces (technically, two epithelialized surfaces), such as blood vessels, intestines, or other h ...

, and nerve damage. Thus, the subcostal approach is preferred. 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.

Technique

Before the procedure, a thorough review of the patient's imaging is conducted to evaluate the anatomy of the

and surrounding structures. The patient's clinical status, medications, and laboratory values (i.e. white blood cell count, coagulation studies, inflammatory markers,

anticoagulation An anticoagulant, commonly known as a blood thinner, is a chemical substance that prevents or reduces the coagulation of blood, prolonging the clotting time. Some occur naturally in blood-eating animals, such as leeches and mosquitoes, which h ...

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 An antiseptic ( and ) is an antimicrobial substance or compound that is applied to living tissue to reduce the possibility of sepsis, infection, or putrefaction. Antiseptics are generally distinguished from ''antibiotics'' by the latter's abil ...

solution to minimize the risk of infection. Local anesthesia, in the form of a topical 1%

lidocaine Lidocaine, also known as lignocaine and sold under the brand name Xylocaine among others, is a local anesthetic of the amino amide type. It is also used to treat ventricular tachycardia and ventricular fibrillation. When used for local anae ...

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 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. The needle is then removed and exchanged with progressively larger

dilator Dilator or dilatator is a medical term with a number of uses, including: *A surgical instrument or medical implement used to induce dilation, that is, to expand an opening or passage such as the cervix (see cervical dilator), urethra, esophagus, ...

s to enlarge the opening into the gallbladder. Finally, an 8 French pigtail

catheter In medicine, a catheter ( ) is a thin tubing (material), tube made from medical grade materials serving a broad range of functions. Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgical procedure. ...

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. # 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.

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 dislodgement, blockage, or a bile leak, which, while frequent, are considered minor complications. Major complications, although rare, encompass

sepsis Sepsis is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage of sepsis is followed by suppression of the immune system. Common signs and s ...

, significant

, and bowel injury. Notably, the transhepatic 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

to prevent future episodes of cholecystitis once the patient is stable for surgery.

Endoscopic cholecystostomy

An alternative to the percutaneous cholecystostomy is to use the

endoscopic An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are insert ...

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.

Endoscopic Transpapillary Gallbladder Drainage

This procedure is performed during an endoscopic retrograde cholangiopancreatography (ERCP). The

cystic duct The cystic duct is the duct that (typically) joins the gallbladder and the common hepatic duct; the union of the cystic duct and common hepatic duct forms the bile duct (formerly known as the common bile duct). Its length varies. Anatomy ...

is cannulated and a plastic

stent In medicine, a stent is a tube usually constructed of a metallic alloy or a polymer. It is inserted into the Lumen (anatomy), lumen (hollow space) of an anatomic vessel or duct to keep the passageway open. Stenting refers to the placement of ...

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 Common bile duct stone, also known as choledocholithiasis, is the presence of gallstones in the common bile duct (CBD) (thus '' choledocho-'' + '' lithiasis''). This condition can cause jaundice and liver cell damage. Treatments include choledocho ...

). Some drawbacks include an increased risk of

pancreatitis Pancreatitis is a condition characterized by inflammation of the pancreas. The pancreas is a large organ behind the stomach that produces digestive enzymes and a number of hormone A hormone (from the Ancient Greek, Greek participle , "se ...

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 In geology, rock (or stone) is any naturally occurring solid mass or aggregate of minerals or mineraloid matter. It is categorized by the minerals included, its Chemical compound, chemical composition, and the way in which it is formed. Rocks ...

, adhesions, strictures,

cancer Cancer is a group of diseases involving Cell growth#Disorders, abnormal cell growth with the potential to Invasion (cancer), invade or Metastasis, spread to other parts of the body. These contrast with benign tumors, which do not spread. Po ...

, or other masses).

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 The stomach is a muscular, hollow organ in the upper gastrointestinal tract of Human, humans and many other animals, including several invertebrates. The Ancient Greek name for the stomach is ''gaster'' which is used as ''gastric'' in medical t ...

or the

duodenum The duodenum is the first section of the small intestine in most vertebrates, including mammals, reptiles, and birds. In mammals, it may be the principal site for iron absorption. The duodenum precedes the jejunum and ileum and is the shortest p ...

. 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

References

{{Digestive system procedures Accessory digestive gland surgery Interventional radiology