What is the proper management and care for a patient with a cholecystostomy tube?

Management and Care of Cholecystostomy Tubes

Primary Indication and Patient Selection

Cholecystostomy tubes are indicated for acute cholecystitis in patients with multiple comorbidities who are unfit for surgery and do not show clinical improvement after antibiotic therapy, though this approach is inferior to cholecystectomy in terms of major complications for critically ill patients. 1

• Percutaneous cholecystostomy serves as either a bridge to interval cholecystectomy or as definitive treatment in patients who remain unsuitable for surgery 2
• Only approximately one-third of patients who receive cholecystostomy tubes will ultimately undergo surgical cholecystectomy 3, 4
• Independent predictors of remaining with a destination tube (no subsequent surgery) include higher Tokyo Grade, higher Charlson Comorbidity Score, and lower albumin levels 4

Antibiotic Management

Antibiotic therapy should be administered for 4 days after cholecystostomy placement in immunocompetent, non-critically ill patients with adequate source control. 1

For Non-Critically Ill, Immunocompetent Patients:

• Amoxicillin/Clavulanate 2g/0.2g q8h 1
• Alternative for beta-lactam allergy: Eravacycline 1 mg/kg q12h or Tigecycline 100 mg loading dose then 50 mg q12h 1

For Critically Ill or Immunocompromised Patients:

• Piperacillin/tazobactam 6g/0.75g loading dose then 4g/0.5g q6h or 16g/2g by continuous infusion 1
• Antibiotic therapy up to 7 days based on clinical conditions and inflammation indices if source control is adequate 1
• For beta-lactam allergy: Eravacycline 1 mg/kg q12h 1

Special Circumstances:

• Patients with inadequate/delayed source control or high risk of ESBL-producing Enterobacterales: Ertapenem 1g q24h or Eravacycline 1 mg/kg q12h 1
• Septic shock: Meropenem 1g q6h by extended infusion, Doripenem 500mg q8h by extended infusion, Imipenem/cilastatin 500mg q6h by extended infusion, or Eravacycline 1 mg/kg q12h 1

Tube Management and Monitoring

Cholecystostomy tubes should be routinely replaced every 3 months or more frequently in patients at high risk for intraluminal obstruction, as colonization and biofilm formation lead to progressive obstruction. 1

• Mean catheter dwell time averages 17 days (range 1-154 days) 2
• Approximately 10% of patients require tube reinsertion, typically occurring at a mean of 38 days after initial removal 2
• Approximately 34% of patients require at least one additional percutaneous procedure for gallbladder drainage 3

Tube Removal Criteria:

• Tubes can be removed safely when patients are clinically well and clean-appearing bile is draining 2
• A tubogram to assess cystic duct patency is not always necessary before tube removal 2
• Approximately 55% of patients have no further biliary intervention after cholecystostomy catheter removal 2

Interval Cholecystectomy Considerations

For patients who undergo interval cholecystectomy after cholecystostomy, surgery should be performed at a mean of 7 weeks after tube placement. 3

• Laparoscopic cholecystectomy in this setting has a 32% conversion rate to open surgery 3
• Major postoperative complications include common bile duct obstruction requiring ERCP, hemoperitoneum requiring reoperation, and bile leak from cystic duct stump 3
• Patients with higher albumin levels are more likely to successfully undergo interval cholecystectomy 4

Critical Pitfalls to Avoid

The average cost of routine tube replacement ($3,000) is substantially lower than treating infectious complications ($40,000 per episode), making scheduled replacement essential. 1

• Delaying tube replacement risks progressive hydronephrosis, renal failure, pyelonephritis, renal abscess, or bacteremia due to intraluminal biofilm obstruction 1
• Patients who have ongoing signs of infection or systemic illness beyond 7 days of antibiotic treatment warrant diagnostic investigation 1
• Approximately 27.9% mortality has been reported in patients managed with cholecystostomy tubes, though most deaths are from non-cholecystostomy-related illness 4
• We may be too conservative in performing interval cholecystectomy, as the procedure can be performed with low complication rates, potentially condemning many patients to destination tubes unnecessarily 4

Preprocedural Antibiotic Prophylaxis

Percutaneous cholecystostomy tube placement is considered a contaminated procedure requiring antimicrobials with enteric coverage, such as ampicillin/sulbactam, if the patient is not already receiving antibiotics. 1

• Standard sterile technique should be used including exclusive operating room, adequate local antiseptic, fully sterile body draping, and sterile gloves 1