Cholecystostomy Tube Placement in Critically Ill Patients

Cholecystostomy Tubes

• 32% of interventional radiologists and/or surgeons should ensure that any critically ill patients who had a cholecystostomy tube placed did not improve or decline clinically after tube placement.
• Coagulopathy should be corrected before tube placement to avoid bile leakage.
• Bile leakage can occur if the tube is dislodged or the gallbladder wall is necrotic, leading to sepsis, diffuse biliary peritonitis, and/or a biloma/abscess in the right upper quadrant.

Long-term Management of Cholecystostomy Tubes

• The management of cholecystostomy tubes after initial treatment remains somewhat controversial.
• There are no broadly accepted guidelines regarding definitive tube management.
• 5% to 63% of patients eventually undergo definitive cholecystectomy, but this is not well defined.

Complications of Cholecystostomy Tubes

• Later complications, such as bile leakage, can occur if the tube is dislodged or the gallbladder wall is necrotic.
• Suspect leakage when a patient's leukocytosis worsens or does not improve after tube placement, or when symptoms initially improve but the patient subsequently develops sepsis, hemodynamic instability, fever, worsening leukocytosis, or worsening abdominal pain.

Classification of Biliary Injuries

• Strasberg and colleagues proposed a modified classification system (Fig. 3) to categorize biliary injuries.
• Involvement of aberrant right hepatic duct alone or with concomitant stricture of the common hepatic duct is important to consider.

Vascular Injury

• Vascular injury can occur concurrently with biliary injury in up to 15% of cases.
• Arterial injury can lead to biliary ischemia and propagate the injury to a higher level than the mechanical injury on the bile duct.
• It is imperative to assess the hepatic arteries when investigating any major biliary injury.

Management of Bile Duct Injuries

• Postoperative care involves cholangiography and biliary drainage.
• Closed-suction drains should be placed in the subhepatic space to control the bile leak and prevent peritonitis or biloma formation.
• Endoscopic dilation and stenting usually manage conditions successfully.

Transection of the Common Bile Duct

• The most common ductal injury involves complete transection of the common bile duct or common hepatic duct.
• Immediate repair should be performed if ductal length can be maintained without tension if recognized at the time of laparoscopic cholecystectomy with appropriate expertise available.

Delayed Presentation of Bile Duct Injuries

• The majority of patients with an iatrogenic biliary injury present in the early postoperative period with symptoms such as fever, jaundice, abdominal pain, or peritonitis.
• A Roux-en-Y jejunal limb is preferred over an anastomosis to the duodenum.
• A transanastomotic stent should be placed across the anastomosis and certainly in cases when two ducts have been transected.

General Approach to Repair of Bile Duct Injuries

• Recognized in the postoperative period, the definitive repair of a bile duct transection should not be planned until the patient has fully recovered from any sepsis or significant inflammation associated with a bile leak.
• A period of 6 to 8 weeks is allowed before repair.
• Complete bile diversion during this period is necessary, and fluid, electrolytes, and hydration must be monitored.

Choledochal Cysts

• Type II cysts comprise about 1% to 3% of all CCs and consist of a saccular diverticulum off of the extrahepatic biliary tree.
• Type III cysts (choledochoceles) consist of biliary ductal dilation within the duodenal wall and make up 1% to 3% of all CCs.
• Type IV cysts are the second most common type of cyst and make up 24% of all CCs.
• Type IV cysts are further subdivided into type IVa, consisting of multiple intrahepatic cysts and a single extrahepatic cyst, while type IVb consists of multiple intrahepatic and extrahepatic cysts.

Diagnosis of Choledochal Cysts

• US is the most frequently used imaging modality to diagnose CC and is the first imaging study recommended in the pediatric population.
• A CBD diameter of >10 mm in an adult on any imaging modality should alert practitioners to the possibility of CC; however, this guideline should be used with caution in older patients, as bile duct diameter increases with age.

Intraoperative Imaging Techniques

• Laparoscopic ultrasonography and near-infrared biliary imaging using indocyanine green or white light technology are alternative intraoperative techniques for imaging biliary anatomy, but are not commonly used due to limited familiarity and lack of high-level evidence.

Classification of Biliary Injuries

• The Bismuth classification system describes biliary injuries based on their location in the biliary tract with respect to the hepatic bifurcation.
• The Strasberg classification system is a modified classification system that includes five types of biliary injuries: A, B, C, D, and E.
• Type A injuries involve cystic duct leaks or leaks from small ducts in the liver bed.
• Type B injuries involve occlusion of part of the biliary tree, typically clipped and divided right hepatic ducts.
• Type C injuries involve transection (but not ligation) of the aberrant right hepatic ducts.
• Type D injuries involve lateral injuries to major bile ducts.
• Type E injuries are further classified into five subtypes: E1, E2, E3, E4, and E5.

Type E Injuries

• Type E1 injuries involve common hepatic duct division, more than 2 cm from bifurcation.
• Type E2 injuries involve common hepatic duct division, less than 2 cm from bifurcation.
• Type E3 injuries involve common bile duct division at bifurcation.
• Type E4 injuries involve hilar stricture, involvement of confluence and loss of communication between right and left hepatic duct.
• Type E5 injuries involve involvement of aberrant right hepatic duct alone or with concomitant stricture of the common hepatic duct.

Vascular Injuries

• Vascular injuries can occur concurrently with biliary injuries, with an incidence of up to 15% of cases.
• The right hepatic artery is the most commonly involved structure in a vasculobiliary injury due to its proximity to the bile duct.
• Arterial injury can lead to biliary ischemia and propagate the injury to a higher level than the mechanical injury on the bile duct.
• Assessment of the hepatic arteries is crucial when investigating major biliary injuries.