What are the guidelines for performing a percutaneous (per cutaneous) cholecystostomy (per chole) tube placement?

Guidelines for Percutaneous Cholecystostomy Tube Placement

Percutaneous cholecystostomy should be performed using the transhepatic approach under ultrasound guidance in high-risk patients (older than 65, with ASA III/IV, performance status 3-4, or septic shock) who are deemed unfit for surgery. 1

Patient Selection

• Percutaneous cholecystostomy is indicated for patients with acute calculous cholecystitis who are high-risk surgical candidates (elderly patients with ASA III/IV, performance status 3-4, or septic shock) 1
• This procedure serves as a bridge to cholecystectomy in acutely ill patients, converting them to moderate-risk patients more suitable for surgery 1
• The procedure can be used when medical therapy has failed to resolve acute cholecystitis 1

Technical Approach

• The transhepatic route is preferred over the transperitoneal approach because it: 1
  • Reduces the risk of biliary leak
  • Allows the drain to be left in place for longer periods
  • Leads to quicker maturation of the drainage tract
• Imaging guidance options include: 1, 2
  • Ultrasound guidance (preferred due to real-time visualization, lack of radiation, and portability)
  • CT guidance
  • Fluoroscopic guidance
• Insertion techniques include: 1, 3
  • Seldinger technique (uses a fine needle, reducing risk of hollow viscus perforation)
  • Trocar technique (allows direct insertion of an 8 French pig-tail catheter)
• Technical success rates reach approximately 90% 1

Potential Complications

• Procedure-related complications occur in approximately 3.4% of cases and may include: 1
  • Bile duct leak and biliary peritonitis
  • Portal or parenchymal vessel injury and bleeding
  • Catheter dislodgement
  • Colon injury
  • Vagal reaction
  • Pneumothorax (with transhepatic approach)
• The transhepatic approach should be avoided in patients with severe liver disease and coagulopathy 1

Post-Procedure Management

• A cholangiogram should be performed 2-3 weeks after placement to assess: 1
  • Cystic duct patency
  • Presence of gallstones
  • Catheter position
• The catheter should be removed between 4-6 weeks after placement if the cholangiogram demonstrates biliary tree patency 1, 4
• Longer catheter dwell times may be necessary for patients with: 1
  • Diabetes
  • Ascites
  • Long-term steroid therapy
  • Malnutrition
• Patients can be discharged home with the drain in place 1

Special Considerations

• In elderly patients, laparoscopic cholecystectomy should still be attempted first except in cases of absolute anesthetic contraindications or septic shock 1
• Percutaneous cholecystostomy can serve as definitive treatment in patients who remain unfit for surgery, with 50% of patients requiring no further biliary intervention after catheter removal 4
• Conversion from percutaneous cholecystostomy to laparoscopic cholecystectomy may be technically challenging due to adhesions, gallbladder wall thickness, and difficulty identifying anatomical structures 1
• A tubogram is not always necessary before tube removal if patients are clinically well and clean-appearing bile is draining 4

Outcomes

• Percutaneous cholecystostomy has a high success rate in reducing inflammatory status and controlling infection in high-risk patients 1
• Approximately 30-40% of patients undergo subsequent cholecystectomy after percutaneous cholecystostomy 1, 4
• 30-day mortality after percutaneous cholecystostomy insertion is approximately 8.3%, reflecting the high-risk nature of the patient population 4