From the Guidelines
A surgeon would not typically put a drain in a patient with cholecystitis as the first line of treatment, but rather consider immediate laparoscopic cholecystectomy as the superior treatment option, especially in high-risk patients, as evidenced by the 2020 World Society of Emergency Surgery guidelines 1. When considering the management of acute calculus cholecystitis (ACC), the primary goal is to reduce morbidity, mortality, and improve quality of life.
- The use of percutaneous transhepatic gallbladder drainage (PTGBD) has been compared to laparoscopic cholecystectomy in several studies, with the most recent and highest quality study, the CHOCOLATE trial, showing that laparoscopic cholecystectomy is superior to PTGBD in high-risk patients with ACC 1.
- Key benefits of laparoscopic cholecystectomy over PTGBD include significantly fewer major complications, reduced recurrent biliary events, and less utilization of healthcare resources 1.
- While drains may be used in certain situations, such as significant inflammation or perforation of the gallbladder, the placement of a drain is not a routine part of cholecystectomy and is typically reserved for cases with a higher risk of fluid collection or contamination of the surgical field.
- The decision to use a drain should be based on individual patient factors, including the severity of inflammation and technical aspects of the procedure, rather than as a standard treatment for cholecystitis.
- Overall, the current evidence supports the use of immediate laparoscopic cholecystectomy as the first-choice treatment for high-risk patients with ACC, rather than relying on drain placement as a primary treatment strategy 1.
From the Research
Reasons for Drain Placement in Cholecystitis
- A surgeon may put a drain in a patient with cholecystitis to remove fluid and reduce pressure in the gallbladder, as indicated by the use of percutaneous cholecystostomy catheters 2, 3, 4.
- Drains can be used as a bridge to surgery or as primary therapy in patients who cannot undergo surgery 2.
- Internalization of percutaneous cholecystostomy drainage catheters using endoscopic ultrasound-guided placement of lumen-apposing metal stents (LAMS) is a viable option for internal gallbladder drainage in patients who are poor candidates for cholecystectomy 2.
- Endoscopic transpapillary drainage (ETP-GBD) and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) are increasingly preferred over percutaneous cholecystostomy tubes (PCT) due to their favorable technical and clinical success combined with lower complication rates 3.
Benefits of Drain Placement
- Reduction of pressure to the surgical site and adjacent organs, nerves, and blood vessels 5.
- Enhancement of wound perfusion and wound healing 5.
- Reduction of pain 5.
- Technical success and clinical success rates are equivalent to those of percutaneous cholecystostomy, with improved pain scores and lower re-intervention rates 6.