What is the management for a patient with a leaking percutaneous (through the skin) cholecystostomy (gallbladder drainage) tube?

Management of Leaking Percutaneous Cholecystostomy Tube

For a leaking percutaneous cholecystostomy tube, immediately assess the tube position and secure it properly with appropriate tension between internal and external bolsters, protect the surrounding skin with zinc oxide-based barriers, and initiate proton pump inhibitors to reduce gastric acid secretion—if these measures fail, the tube may need replacement at the same site or repositioning. 1

Initial Assessment and Immediate Interventions

Verify Tube Position and Tension

• Check the distance between internal and external fixation devices—the tube should be advanced into the gallbladder 5-10 cm with small in-and-out movements (not rotation) to ensure proper positioning without excessive compression. 1
• Excessive compression between bolsters is the most important risk factor for buried bumper syndrome and subsequent leakage. 1
• The tube should not be too loose or too restrictive—improper tension is a primary cause of peristomal leakage. 1

Skin Protection Protocol

• Apply zinc oxide-based skin protectants immediately to the peristomal area to prevent skin breakdown from bile exposure. 1
• Use foam dressings rather than gauze—foam lifts drainage away from skin while gauze contributes to maceration. 1
• Topical barrier films, pastes, or creams containing zinc oxide should be applied as first-line skin protection. 1

Medical Management

• Start proton pump inhibitors to decrease leakage by minimizing gastric acid secretion, though this applies more to gastrostomy tubes than cholecystostomy tubes. 1
• Review PPI use regularly as it may not be necessary long-term. 1

Identify and Address Underlying Causes

Common Risk Factors for Leakage

• Skin infection at the insertion site 1
• Gastroparesis or increased abdominal pressure (though less relevant for cholecystostomy) 1
• Constipation causing increased intra-abdominal pressure 1
• Side torsion of the tube leading to tract enlargement 1
• Granulation tissue formation in the tract 1
• Patient factors: diabetes with hyperglycemia, immunosuppression, malnutrition 1

Specific Interventions Based on Cause

• If local infection is present, treat with appropriate antibiotics and consider topical antifungal agents if fungal infection is suspected. 1
• If excessive granulation tissue is present at the stoma site, this requires specific management (cauterization or topical agents). 1
• If side torsion has enlarged the tract, stabilize the tube using a clamping device or consider switching to a different tube type. 1

Tube-Specific Troubleshooting

For Balloon-Retained Catheters

• Verify the balloon volume corresponds with manufacturer's recommendations and check weekly. 1
• Ensure correct balloon size and tube length are being used. 1

When Conservative Measures Fail

• Replacing the tube with a larger-diameter tube is NOT recommended as it typically enlarges the tract further and worsens leakage. 1
• In refractory cases, remove the tube for 24-48 hours to permit slight spontaneous tract closure, then replace with a tube that fits more closely. 1
• If all measures fail, place a new cholecystostomy at a different location. 1

Timing Considerations for Tract Maturation

• The transhepatic approach is preferred as it reduces bile leak risk and allows longer indwelling time with quicker tract maturation compared to transperitoneal approach. 1
• Tube mobilization should begin approximately one week after placement, but if gastropexy sutures are present, delay mobilization until sutures are removed (usually two weeks). 1
• The cholecystostomy catheter should remain in place for 4-6 weeks to allow tract maturation before removal. 1
• In patients with diabetes, ascites, long-term steroid therapy, or malnutrition, leave the drain in place longer as these conditions hinder tract maturation. 1

Critical Pitfalls to Avoid

• Do not delay enteral nutrition or stop drainage completely unless leakage is massive—most leaks can be managed with local measures while maintaining drainage function. 1
• Do not assume the tube is properly positioned without verification—even if the tube rotates, it can still be embedded in tissue. 1
• Do not ignore signs of infection—peristomal infection significantly increases leakage risk and requires prompt treatment. 1
• Do not remove the tube prematurely before tract maturation (minimum 4 weeks)—this increases bile leak risk after removal. 1

When to Consider Tube Replacement or Removal

• If conservative measures fail after optimizing all factors above, tube replacement may be necessary. 1
• Before tube removal, perform cholangiography via the drain to ensure cystic duct patency—a patent cystic duct reduces post-removal leak risk. 1
• Technical success of cholecystostomy placement is approximately 90%, with failure due to small gallbladder lumen, thin wall, or porcelain gallbladder. 1