What are the risks and management strategies after removing the catheter following percutaneous cholecystotomy, considering the remaining hole in the gallbladder?

From the Guidelines

After removing a catheter following percutaneous cholecystotomy, the main risks include bile leakage, peritonitis, and infection due to the remaining hole in the gallbladder, and management strategies should focus on proper timing of catheter removal and post-procedure care, as outlined in the 2019 guidelines 1. The catheter should only be removed after tract maturation, which typically occurs between 4 and 6 weeks after placement, as stated in the guidelines 1. Prior to removal, a cholangiogram should be performed to confirm biliary tree patency and the absence of leak or obstructed cystic duct, as recommended by the guidelines 1. Key considerations for catheter removal include:

• The patient should be clinically stable with resolved infection and inflammation
• A cholangiogram via the drain is recommended before drain withdrawal to ensure the absence of leak or obstructed cystic duct 1
• The procedure may include gradual downsizing of the catheter before complete removal
• Post-removal monitoring for 4-6 hours is essential to detect complications like pain, fever, or signs of peritonitis
• Patients should be instructed to report symptoms such as fever, increasing abdominal pain, or bile-colored drainage from the site The hole typically seals spontaneously as the gallbladder contracts and the tract collapses, with complete healing occurring within days to weeks, facilitated by the gallbladder's muscular wall and the body's tissue repair mechanisms, although the exact mechanism is not explicitly stated in the guidelines 1.

From the Research

Risks After Catheter Removal

• The removal of the catheter after percutaneous cholecystotomy can lead to bile leaks, which may be major or minor 2.
• Major bile leaks occurred in 3% of patients, while minor leaks occurred with equal frequency 2.
• The risk of complications associated with the catheter is high, and removing the catheter when acute cholecystitis is controlled may help prevent morbidity related to percutaneous cholecystostomy 3.

Management Strategies

• Tract imaging may not be necessary in patients with small-bore gallbladder catheters who have recovered from critical illness, show patent cystic and common ducts, and have had catheters for 3-6 weeks 2.
• Removing the catheter when acute cholecystitis is controlled may help prevent morbidity related to percutaneous cholecystostomy 3.
• The optimal timing for catheter removal is not well established, but most studies suggest removing the tube after more than 4 weeks from insertion 4.
• Interval cholecystectomies are more frequently performed after 5 weeks from percutaneous gallbladder drainage (PGD) 4.

Clinical Outcomes

• Patients with moderate acute cholecystitis who received narrow-spectrum antibiotics after percutaneous cholecystostomy had comparable clinical outcomes to those treated with broad-spectrum antibiotics 5.
• In severe acute cholecystitis, broad-spectrum antibiotics might still be necessary to rescue these patients 5.
• The timing of endoscopic retrograde cholangiopancreatography (ERCP) is not a significant predictor of post-ERCP adverse events after biliary duct leaks, but combination or stent monotherapy had lower failure rates compared to sphincterotomy monotherapy 6.