Procedure Guides
Gastrointestinal and Urinary

Cholecystostomy Tube

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Procedure Guide

Indications

Acute cholecystitis in a non-surgical candidate (drainage does not help chronic cholecystitis)

Tokyo Guidelines for Cholecystitis 2013

  • Diagnostic criteria for acute cholecystitis:

    • Local signs of inflammation (A): Murphy’s sign or RUQ pain

    • Systemic signs of inflammation (B): Fever, elevated CRP, or leukocytosis

    • Imaging findings of cholecystitis (C)

    • Suspected diagnosis: one A item + one B item

    • Definite diagnosis: above + C

  • Grade I (mild): not meeting grade 2 or 3 -> abxs, supportive care, cholecystectomy

  • Grade II (moderate): WBC >18, RUQ tenderness, duration >72 hrs, marked local inflammation (abscess, gangrenous, peritonitis, emphysematous) -> 24-48 hr trial of abxs and supportive care -> cholecystectomy unless failure of therapy

  • Grade III (severe): organ dysfunction in terms of hypotension requiring pressor, AMS, PaO2/FiO2 <300, Cr >2, INR >1.5, or plt <100 -> hemodynamic support -> urgent GB drainage

  • Severe existing systemic disease (SESD): preexisting organ dysfunction with imaging evidence of cholecystitis but WITHOUT reliable focal signs/symptoms of cholecystitis -> often a false positive when studied, treat the patient not the imaging!

Contraindications

Uncorrected coagulopathy (Plt <50K, INR >1.5)

Infected tumor - unlikely to resolve the infection

Efficacy and alternatives

Percutaneous cholecystostomy: Nearly 100% technically successful. Main issues include requiring the tube in place for weeks to months with tube management at home and issues with pain and dislodgment. There are promising percutaneous interventions for those who will never be a surgical candidate such as cholangioscopy with lithotripsy and stone removal.

Antibiotics alone: Some studies suggest similar outcomes to cholecystostomy tube placement with clinical improvement in 86% vs 87% of patients

Endoscopic ultrasound-guided cholecystostomy: Systematic review showed no difference in technical or clinical success. The endoscopic approach had fewer adverse events, shorter hospital stays, and fewer reinterventions and readmissions.

Cholecystectomy: Gold standard and most definitive intervention. CHOCOLATE trial suggested less complications with cholecystectomy in high risk patients vs percutaneous cholecystostomy (65% vs 12% complications, respectively).

Pre-procedure care

Hold coumadin/Plavix/ASA 5d, Eliquis 48 hrs, heparin 24 hrs if possible

Prophylactic antibiotic coverage if not already being treated with antibiotics (e.g. Piperacillin / Tazobactam)

PT/INR, CBC, LFTs

procedure

Cholecystostomy Tube Placement

  • Use ultrasound to plan approach. 

  • Access the gallbladder under ultrasound-guidance

    • Can use a 22G or 21G needle (e.g., chiba) and access set (e.g. Greb Set) OR use a Yueh or 19G coaxial to go straight to an 0.035” wire.

    • Some advocate for targeting access to the gallbladder neck vs fundus

  • Aspirate bile for culture

  • Can confirm access with gentle contrast injection if using fluoroscopy

  • Advance 0.035” working wire, e.g., Amplatz

  • Dilate percutaneous tract

  • Place and form drain - often 8.5 or 10.2 Fr locking pigtail drainage catheter

  • Confirm positioning with gentle contrast injection if using fluoroscopy. Avoid over pressuring the infected gallbladder.

  • Some suggest aspirating out gallbladder contents.

  • Can stitch in place but taping may be better to let the tube move with aspiration

Percutaneous Cholecystolithotomy or Lithotripsy

  • Dilate tract (ideally transperitoneal) to 26-30 Fr. Can use an 8 or 10 mm balloon and then place sheath.

  • Optional cholangioscopy to visualize and laser lithotripsy for larger stones.

  • Can fish out larger stone fragments with a basket or flush out small debris with balloon up in the cystic duct and continuous irrigation.

  • Cholecystostomy tube often left at the end for capping trial and removal at a later date.

  • Outcomes: successful in ~73%, recurrance in 41%, complications (mainly bile leak) in 9%

Gallbladder Ablation

  • Ideally done without substantial gallstones, which can serve as a nidus for infection.

  • Contrast injection through cholecystostomy tube to estimate volume to fill the gallbladder and ensure no passage through the cystic duct.

  • Estimated volume of ethanol is injected and left to dwell for 30 minutes.

  • Ethanol is removed and estimated volume of STS is injected and left to dwell for 30 minutes.

  • Some remove the cholecystostomy tube vs leaving in place capped and return in 1-2 weeks for further ablation if needed.

Complications

Tube dislodgement/displacement 4.5-13.2%

Bile leak ~2%

Bleeding requiring transfusion <2%

Worsening sepsis and mortality <1%

Post-procedure care & Follow Up

  • Drain to gravity

  • Flush drain daily to maintain patency

  • Drain will need to stay in place for at least 2-6 weeks for tract maturation or until surgery. Should have clinical improvement in 1-3 day unless gangrenous.

  • Drain will need routine exchanges every 3 months if in place longer than 6 weeks.

    • Can perform a cholecystogram at that time and consider capping trial if the cystic duct is patent.

    • Cholangioscopy can also be considered for stone removal. Transperitoneal access tends to be superior for this as it requires upsizing the access.