Cholecystostomy and Transcholecystic Biliary Access PDF

Cholecystostomy and Transcholecystic Biliary Access Daniel Ginat, MD, MS, and Wael E.A. Saad, MBBCh Percutaneous cholecystostomy represents a minimally invasive procedure for providing gallbladder decompression, often in critically ill patient populations....

Cholecystostomy and Transcholecystic Biliary Access Daniel Ginat, MD, MS, and Wael E.A. Saad, MBBCh Percutaneous cholecystostomy represents a minimally invasive procedure for providing gallbladder decompression, often in critically ill patient populations. Indications for this procedure include calculous and acalculous cholecystitis, gallbladder perforation, malig- nant obstruction, percutaneous biliary stone removal, biliary duct drainage, and diagnostic imaging of the gallbladder and biliary ductal system. In addition, gallbladder access provided by percutaneous cholecystostomy may serve to carry additional procedures, such as cholangiograms, gallstone dissolution, and lithotripsy. Review of prior imaging studies including ultrasound, CT, and hepatobiliary scans are essential to planning the procedure, by helping to determine the access route: transhepatic versus transperitoneal. The trans- hepatic route is preferred in cases of large ascities, bowel interposition, and offers the advantage of greater catheter stability. On the other hand, the transperitoneal route is preferred in the setting of coagulopathy and liver disease. Initial access is gained via insertion of an 18- to 22-gauge needle, followed by use of the Seldinger technique or trocar system to catheterize the gallbladder. Overall technical success rate for percutaneous cholecystostomy is greater than 95%. Clinical improvement is achieved in 56 to 93% of patients. Complications occur in 3 to 13% of cases and are mainly acute and minor. Major complications such as bile peritonitis, significant hemorrhage, and hemo/pneumothorax affect less than 5% of patients. However, sepsis and reported 30-day mortality rates of up to 25% are usually related to underlying morbidities in critically ill patients. Catheters may be removed once the fistula track has matured. Tech Vasc Interventional Rad 11:2-13 © 2008 Elsevier Inc. All rights reserved. KEYWORDS percutaneous cholecystostomy, gallbladder decompression, cholecystitis, percu- taneous biliary drain, stone removal P ercutaneous cholecystostomy represents an appropriate means of providing gallbladder drainage in cases of gan- grenous, calculous, and acalculous cholecystitis and malig- ical variations that render endoscopic drainage unfeasible, such as following the Billroth II procedure. A comprehensive list of indications for percutaneous cholecystostomy is de- nant obstruction in patient populations that have a high ex- tailed in Table 1. pected morbidity and mortality associated with more Since the inception of percutaneous cholecystostomy in invasive procedures, such as cholecystectomy.1,2 Indeed, the 1970s, numerous variations of the technique have mortality rates related to surgical intervention for cholecysti- evolved and proven effective. The general steps involved in tis in critically ill patients approaches 15%.3,4 Conditions that percutaneous cholecystostomy are outlined in Figure 1 and virtually preclude surgical intervention are encompassed by the most commonly used and latest techniques and periop- American Society of Anesthesiologists (ASA) classifications 3 erative management are described in more detail in the fol- and 4. This includes critically ill patients that experience lowing sections. hemodynamic instability, severe cardiac ischemia, respira- tory distress, renal failure, and significant central nervous system disease.5 Percutaneous cholecystostomy may also be a Preintervention suitable, minimally invasive alternative for gallbladder de- compression in pregnant patients and patients with anatom- Management and Planning Once informed consent for the procedure is obtained, a co- agulation panel should be drawn and coagulopathies cor- Department of Imaging Sciences, University of Rochester Medical Center, rected. Prophylactic antibiotics, generally aminoglycosides Rochester, NY, USA. Address reprint requests to: Wael E.A. Saad, MBBCh, Department of Imag- and cephalosporins, are administered 12 to 24 hours before ing Sciences, University of Rochester Medical Center, 601 Elmwood Ave, percutaneous cholecystostomy.6 For patients that have not Box 648, Rochester, NY 14642. E-mail: [email protected]. already received antibiotics, Zosyn; Wyeth Pharmaceuticals, 2 1089-2516/08/$-see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1053/j.tvir.2008.05.002 Biliary access in cholecystostomy 3 Table 1 Indications for Percutaneous Cholecystostomy Gall Bladder Indications Common Bile Duct Indications (More-Common Indications) (Less-Common Indications) A. Drainage of the gall bladder. A. Drainage of the biliary ducts through a patent cystic duct and Calcular cholecystitis through the cholecystostomy drain. Acalculous cholecystitis B. Providing a portal (percutaneous access) for minimal invasive Iatrogenic/traumatic gall bladder perforation (bile leak) interventions for the common bile duct. An internal/external A. Providing percutaneous access for minimal invasive transcholecystic biliary drain can be placed to drain the gall interventions, such as percutaneous removal of bladder and the common bile duct. biliary stones. C. Diagnostic opacification of the biliary tract including Fluoroscopic-guided stone removal decompressed intrahepatic bile ducts after failed PTC to Percutaneous endoscopic and fluoroscopic stone opacify the ducts. This makes it possible for a more precise removal and/or lithotripsy and more selective percutaneous transhepatic biliary drain placement. Figure 1 Flowchart describing the approach for a cholecystectomy, its technical stages and drain management. 4 D. Ginat and W.E.A. Saad Figure 2 Axial CT images to help describe needle trajectory planning (transhepatic versus transperitoneal). (A) Axial CT image demonstrating an anatomic lay out with a distended gall bladder (GBl) that can be accessed along its long axis transperitoneally (solid long arrow) or transhepatically through the liver (L) (dashed arrow). The asterisk marks a small volume of perihepatic ascites. K, kidney. (B) Axial CT image demonstrating an anatomic lay out with a distended gall bladder (GBl) that can be accessed transhepatically through the liver (L) along its long axis (solid long arrow). When deciding to access along the long axis of a gall bladder for possible subsequent interventions, the axis can be transhepatic or transperitoneal depending on the anatomy and location of the gall bladder. K, kidney. Figure 3 Hepatobiliary scan of a patient with a clinical suspicion of acalcular cholecystitis. (A) Hepatobiliary scan demonstrating prompt uptake of radiotracer by the liver with excretion into the small bowel. The gallbladder is not visualized for 60 minutes after the radiotracer injection (arrow). (B) Hepatobiliary scan after readministration of radiotracer and morphine injection demonstrating no gallbladder visualization up to 30 minutes from the procedure (arrow). Biliary access in cholecystostomy 5 Inc., Philadelphia, PA (piperacillin and tazobactam) can be Techniques administered intravenously immediately before the proce- dure. A large proportion of candidates for percutaneous cho- Percutaneous cholecytostomy is initiated with insertion of an lecystostomy are intensive care unit patients who do not have 18- to 22-gauge needle under direct ultrasound visualization oral intake and have distended gallbladders. If not already nil from an anterior or right anterolateral approach (Figs. 5C and per os (NPO), patients are to be made NPO the night before D and 6C). The needle is advanced, so as to not puncture the the intervention to maximally distend the gallbladder and distal/posterior wall of the gallbladder. Access into the gall- minimize bowel gas that may interfere with the procedure. bladder is ascertained by the aspiration of bile. Confirmation of proper positioning can also be identified under fluoros- Local anesthesia can be provided in combination with mod- copy by injecting less than 5 mL of contrast, to avoid overd- erate sedation, usually intravenous medazolam and fentanyl. istending the gallbladder (Figs. 5E and 6D). In the event that Preprocedure planning involves reviewing available cross- the needle is erroneously inserted within the peritoneal cav- sectional imaging and hepatobiliary nuclear scans. CT and ity, the needle can be repositioned slowly while contrast is ultrasound can be used to evaluate the size and orientation of injected, if fluoroscopy is utilized. The alternative is to per- the gall bladder and the type of percutaneous window to the form a de novo ultrasound-guided gallbladder access. gallbladder (transperitoneal versus transhepatic) (Fig. 2). It is Subsequently, two basic gallbladder access routes can be also important to assess for focal gallbladder wall thickening employed for percutaneous cholecystostomy: transhepatic or masses, such that these areas can be avoided. Similarly, the and transperitoneal (Fig. 2). Transhepatic puncture ideally interventionalist must evaluate the hepatic segment that may consists of traversing the liver parenchyma hypothetically via be traversed by the cholecystostomy drain and make sure it is the bare area of the gallbladder (superior third portion of the free of cysts and/or masses. Evaluating the anatomy helps gallbladder) (Fig. 7). Transhepatic needle trajectories that do plan the needle trajectory for the cholecystostomy and re- not traverse the bare area of the gallbladder also have a par- duces the likelihood of transgressing adjacent organs with tially transperitoneal course (Fig. 7). In practice, however, subsequent major complications. In particular, the right co- less than half of attempts to enter the bare area during trans- lon is an organ that may be inadvertently traversed. This may hepatic cholecystostomy succeed.9 Transhepatic cholecys- make the operator consider approaching the gallbladder tostomies that pass via the bare area have a theoretically lower transhepatically, if there is close proximity of colon to the incidence of bile leak compared with the transperitoneal ap- fundus of the gall bladder if the transperitoneal approach is proach, although this assumption remains controversial and proposed. is not evidence based. Nevertheless, the transhepatic tech- In cases in which cross-sectional imaging and clinical di- nique has the advantage of providing greater catheter stability agnosis of cholecystitis are ambiguous, hepatobiliary nuclear and more rapid track maturation to the direct transperitoneal scans may be helpful. This is often the case in critically ill approach, particularly in the setting of ascites. In addition, patients, in whom the classic clinical presentation may be the transhepatic approach is the safest method in the setting masked by the use of narcotic analgesics and sedatives. Non- of massive ascites and bowel interposition between the liver visualization of the gallbladder after administration of mor- and gallbladder. phine is a sensitive indicator of cholecystitis (Fig. 3). How- The transperitoneal route is considered a more suitable ever, false-positive scans result from long-term fasting and option in patients with liver disease and uncorrected coagu- total parenteral nutrition.7,8 lopathy. The presence of pericholecystic infiltrates also facil- itates the use of the transperitoneal route because of a pre- sumably lower risk of bile leakage. Similarly, the availability Image Guidance Options of anchoring devices that narrow the gap between the gall- bladder and abdominal wall has decreased the incidence of Dynamic two-dimensional ultrasound mounted on steering bile peritonitis associated with the direct approach. The cur- guidance systems has been developed for gallbladder needle rent authors utilize both the transhepatic and the transperi- puncture procedures (ATL, Philips, and HDI 2000 scanner).8 toneal routes based on the decision tree shown in Figure 8. Although somewhat cumbersome, such devices enable con- Also please see Figure 2 and its legends. trolled needle insertion. Roughening the needle tip improves Subsequent catheter insertion can be accomplished using its visibility under ultrasound. Typical ultrasound frequen- either the Seldinger exchange technique or trocar technique. cies utilized for this procedure are in the 2 to 5 MHz range. Often the Seldinger technique is used in combination with Ultrasound offers the advantage of continuous visualization, the transhepatic approach, since this enables the use of small- mobility, low-cost, and availability without exposure to ion- er-gauge needles, thus limiting the risk of hepatic injury. izing radiation. As a result, interventional radiologists rarely Commercially available percutaneous access kits including resort to CT guidance for percutaneous cholecystostomy. the Accustick II introducer system (Boston Scientific, Natick, The only conceivable indication for utilizing CT and not ul- MA) and Neff percutaneous access set (Cook Medical, trasound is a significantly diseased gallbladder in the case of Bloomington, IN) enable one to upsize the 0.018-inch plat- calcular cholecystitis and wall thickening in which the oper- form to a 0.035-inch platform; that is if the operator feels the ator cannot clearly identify a lumen by ultrasonography but need to utilize a low-caliber needle such as 20- to 22-gauge can identify the decompressed/ruptured gallbladder by CT needles. Alternatively, a 0.035-inch wire can be inserted di- (Fig. 4). Once needle placement is achieved under ultra- rectly through a 18- or 19-gauge needle. After the guidewire sound guidance, catheter insertion is commonly performed is securely coiled inside the gallbladder lumen, the needle is under fluoroscopy (Figs. 5 and 6). then removed, and serial track dilatations are performed us- 6 D. Ginat and W.E.A. Saad Figure 4 CT-guided cholecystostomy. (A) Grayscale ultrasound demonstrating a large stone (St) with a decom- pressed lumen (the lumen is not clearly identified). The liver (L) is seen adjacent to the gall bladder stone. (B) Axial CT image with skin markers demonstrating a large gall bladder stone (arrow). The gall bladder fundus is dense (arrowhead). It may have inspisated bile or proteinaceous mucus that may be the reason why the lumen was not seen clearly by ultrasound and why it is dense by CT. (C) Axial CT image after passing an 18-gauge needle into the high density fundus (arrow). (D) Two cropped axial CT images of the right upper quadrant after passing a 0.035-inch wire (arrow) where it circumvents around the gall bladder stone (arrowhead). (E) Two cropped axial CT images of the right upper quadrant after passing a 8-French drain (arrow), where it circumvents around the gall bladder stone (arrowhead). Biliary access in cholecystostomy 7 Figure 5 Ultrasound followed by fluoroscopic-guided cholecystostomy. (A) Axial CT image of the abdomen before cholecystostomy drain placement. The gall bladder (GBl) is visualized between the liver (L) and the large bowel (contrast). The asterisk represents a small volume of perihepatic fluid/ascites. K, kidney(s). (B) Grayscale ultrasound with a fused schematic (line drawing) for clarification and labeling demonstrating a gall bladder with wall thickening. The liver (L) is seen adjacent to the gall bladder with fluid around it (asterisks). #, the gall bladder lumen. The arrow points to the gall bladder wall. (C) Grayscale ultrasound with a fused schematic (line drawing) for clarification and labeling demonstrating a gall bladder with wall thickening. The liver (L) is grazed by the needle. The needle is slightly off the needle path aligned by the ultrasound machine. At this moment in time, the needle tip is pushing against the bladder wall (arrow). 8 D. Ginat and W.E.A. Saad FIGURE 5 (Cont’d). (D) Grayscale ultrasound with a fused schematic (line drawing) for clarification and labeling demonstrating a gall bladder with wall thickening. The liver (L) is grazed by the needle (arrow) and is in the gall bladder lumen (arrow). (E) Fluoroscopic caption after ultrasound needle access and injection of contrast. The needle (arrow) is in the gall bladder (GBl). CD, cystic duct; CBD, common bile duct. (F) Fluoroscopic caption during an attempt to pass an 8-French dilator over the wire into the gall bladder. The dilator tip is at the gall bladder entry site (between arrows) and it is bending despite good wire countertension. This might be due to lack of tissue support: the perihepatic ascites and not going through enough hepatic substance. The wire is buckled at the cystic duct origin. CBD, common bile duct. (G) Fluoroscopic caption as an 8-French drain (black arrow) is being passed over the wire into the gall bladder. The drain tip is in the gall bladder. The wire is buckled at the cystic duct origin (white arrow). CBD, common bile duct. Biliary access in cholecystostomy 9 Figure 6 Ultrasound followed by fluoroscopic-guided cholecystostomy. (A) Axial CT image of the abdomen before chole- cystostomy drain placement. The gall bladder (GBl) is visualized between the liver (L) and the duodenum. The gall bladder has a thickened an irregular wall. K, kidney(s). St, body of stomach; A, antrum; L, liver. (B) Grayscale ultrasound demon- strating the gall bladder with wall thickening and irregularity. The wall is 1.7-cm thick. The lumen of the gall bladder is seen (L). (C) Grayscale ultrasound with a fused schematic (line drawing) for clarification and labeling demonstrating a gall bladder with wall thickening. The needle is in the lumen of the gallbladder (arrow). (D) Fluoroscopic caption during contrast injection into the gall bladder (GBl). Contrast opacifies the intrahepatic ducts (arrowheads) via the cystic duct (CD). Filling defects are identified in the gall bladder consistent with gall bladder stones. The common hepatic duct merges with the cystic duct to form the common bile duct. (E) Fluoroscopic caption during the passage of the wire into the gall bladder (GBl). The wire tip is in the cystic duct. Contrast opacifies the intrahepatic ducts (arrowheads) via the cystic duct. Filling defects are identified in the gall bladder consistent with gall bladder stones. (F) Fluoroscopic caption after an 8-French drain (arrow) has been passed into the gall bladder. Arrowheads point to the intrahepatic bile ducts. CD, cystic duct; CHD, common hepatic duct; CBD, common bile duct. 10 D. Ginat and W.E.A. Saad Figure 7 Schematic demonstrating the transperitoneal and transhepatic routes of accessing the gall bladder percutena- neously. (A) Line drawing demonstrating the bare area of the gall bladder, where there is no peritoneal coverage of the gall bladder. The bare area is formed by the reflections of the peritoneal linings off the gall bladder and liver. Transhepatic passage through the bare area does not allow leakage into the peritoneum since the peritoneal reflections are intact. CD, cystic duct; CBD, common bile duct. (B) Line drawing demonstrating the transhepatic routes to the gall bladder in relation to the bare area of the gall bladder. Approximately 50% of transhepatic passes do not pass through the bare area. If the intent of making a transhepatic passage is to avoid the peritoneal lining then there is a 50% chance of not achieving this aim. (C) Line drawing demonstrating the transperitoneal route to the gall bladder along the long axis of the gall bladder. This route may bring the access closer to the large bowel. How close? This depends on the individual patient anatomy. Note: LB, large bowel; SmB, small bowel. Figure 8 Flowchart describing the thought process of which route to chose (transhepatic versus transperitoneal chole- cystostomy) depending on the clinical situation, the pathology, and the anatomy. Figure 9 Schematic demonstrating the transperitoneal access of the gall bladder where gall bladder wall displacement can pose a problem in placing a cholecystostomy drain. (A) Line drawing demonstrating the coronal section of the right upper quadrant through the gall bladder and the right hepatic lobe. (B) Line drawing demonstrating the transperitoneal needle passage through the fundus of the gall bladder. The wire is looped in a figure of eight in the gall bladder. (C) Line drawing demonstrating the displacement of the fundus away from the access site. The fundus is being pushed away by the dilator. The operator may not notice this, particularly when not using fluoroscopy and occasionally under fluoroscopy with little contrast opacification in the gall bladder. The operator should be aware of this possibility. Good countertension on the wire and a forceful, but controlled, push of the dilator is required to avoid this. (D) Line drawing demonstrating the final outcome of displacement of the fundus away from the access site. The drain will ultimately be deployed/curled outside the gall bladder, leaving the access hole in the fundus, which would possibly leak bile into the peritoneum. 12 D. Ginat and W.E.A. Saad ing an 8-French fascial dilator. The dilator must also skewer Table 2 Major Complications of Percutaneous Cholecystostomy the gallbladder wall rather than displace it (Figs. 5F and 9). Complication Incidence (%) Once the track is sufficiently enlarged, a 6- to 10-French Cholangitis/sepsis Not uncommon* retaining pigtail loop catheter within a cannula is inserted Hemorrhage requiring transfusion 1.6-2.2 into the gallbladder lumen over the guidewire. The guidewire and/or embolization can then be removed and the catheter is advanced and se- Biliary leak and peritonitis 2.4-4.4 cured internally by a “cope loop” and externally by a suture Hemo- and/or pneumothorax Rare tied to the catheter via a mesentery.8,10 30-Day mortality (not related to 0-25 On the other hand, the trocar technique works well in procedure)** conjunction with the transperitoneal route, due to a dimin- *Not necessarily due to procedure. Sepsis and/or cholangitis is ished risk of bile leakage with this more consolidated system. often present before and during the procedure (part of the indi- If the trocar method is resorted to, a small caliber 6- to cations of cholecystostomy). As a result, the actual incidence of 7-French drain is used. The ideal gall bladder is a distended sepsis attributable to cholecystostomy is difficult to assess. **The wide range of mortality depends on the underlying morbidity of one with a safe transperitoneal window with a well-defined the patient population. gall bladder wall by CT and/or ultrasound. The trocar tech- nique involves producing a skin incision using a scalpel along the midclavicular line just inferior to the costal margin. The toneal cavity, subhepatic, subcapsular, and subdiaphrag- catheter is loaded on the trocar with sharp-end stylet and the matic spaces, the tract is deemed mature. Otherwise, a cath- components are introduced into the gallbladder as one unit. eter is reinserted over the guidewire and imaging is repeated Proper placement is confirmed by removing the stylet and 1 week later.7 sampling fluid. If bile is aspirated, the catheter is further Once a mature tract has formed, additional procedures can advanced through the trocar and fixed in the gallbladder. If be conducted, such as percutaneous stone extraction or dis- no bile is aspirated, the system is retracted while continu- solution. Although percutaneous cholecystostomy is gener- ously exerting suction. If bile is recovered during this pro- ally a temporary measure, some patients benefit from long- cess, the catheter can be advanced. If bile return is still not term catheter drainage. In such cases, catheter exchanges achieved, the trocar system is reset and a second attempt is should be performed every 3 months.7 Regardless of the du- made. It is helpful to estimate and mark the maximal possible ration, percutaneous cholecystostomy does not preclude depth of the catheter into the gallbladder based on imaging cholecystectomy at a later stage. However, there is an in- measurements before the procedure.11 creased rate of conversion from laparoscopic to open chole- Catheter position is confirmed by aspirating bile, which cystectomy in this patient population.8 can then be sent for laboratory analysis, including culture, sensitivity, and cytology. A cholecystogram can be performed to evaluate gallbladder anatomy and pathology, such as cho- Outcome and Complications lelithiasis. Injection of only a small amount (⬍5 mL) of con- Technical success rates for percutaneous cholecystostomy centrated (5%) contrast is recommended to avoid exacerba- are on the order of 95 to 100%.7,13,14 The endpoint of chole- tion of sepsis. If a substantial pericholecystic fluid collection cystostomy is securing a pigtail catheter within the gallblad- is present, an additional 10- to 14-French catheter may be der. Technical failures tend to occur in the setting of decom- inserted into that space.12 The catheters are secured using pressed gallbladders, gallbladders with impacted stones, suture material, such as 2- to 0- polypropylene mesh, and porcelain gallbladders, and significant gallbladder wall thick- allowed to drain to gravity. ening. Clinical and laboratory improvement is achieved in 56 to 93% of patients within 2 to 3 days after the procedure.7,15-18 Postintervention Management Clinical success is defined as improvement in sepsis with After the procedure, vital signs should be monitored for 2 to reduction of temperature less than 37.5°C and/or reduction 4 hours basis and antibiotics are continued for at least an- in white blood cell count by 25% of preprocedure levels, or a other 48 hours. If not intubated, patients may be started on a reduction of white blood cell count to less than 10,000/mm3 clear liquid diet later in the day and given analgesics as within 72 hours of the procedure. needed. The catheter should be flushed with 5 to 10 mL of Postintervention mortality rates range from 0 to sterile water or normal sodium chloride solution at least ev- 25%7,8,17,18 results from underlying from underlying precar- ery 24 hours to prevent catheter obstruction. After 3 days, a ious medical conditions in the critically ill patient population cholecystogram with or without cholangiography (if cystic duct that undergo percutaneous cholecystostomy. However, the is patent) can be performed to evaluate catheter position, the estimated mortality rate directly attributable to the procedure presence of stones, and cystic and common bile duct is less than 2%.8 The major complications related to percu- patency.7,11 taneous cholecystostomy are listed in Table 2. Most compli- Fourteen days after the procedure, fistulography is per- cations are acute, becoming apparent within the first few days formed.7 This involves aspirating bile and injecting 10 to 15 of the intervention and occur at an overall rate of 3 to 13% mL of contrast through the catheter to assess the patency of (8%).6,7,14-16 These mainly include bile leaks, malpositioned the cystic and common bile ducts. If these appear patent, a catheters with resultant bowel perforation, vasovagal reac- guidewire is inserted and the catheter can be removed. Ad- tions, and sepsis. The risk of sepsis can be lessened by prac- ditional nondiluted contrast is injected through the track ticing minimal catheter and guidewire manipulation. Late via a vascular sheath. If contrast does not leak into the peri- complications consist of abdominal wall abscess, recurrent Biliary access in cholecystostomy 13 cholecystitis, and catheter dislodgment, which are mainly 8. Sosna J, Copel L, Kane RA, et al: Ultrasound-guided percutaneous due to inadequate fixation and inadvertent patient move- cholecystostomy: Update on technique and clinical applications. Surg Technol Int 11:135-139, 2003 ment. 9. Nemcek AA Jr, Bernstein JE, Vogelzang RL: Percutaneous cholecystos- As stated earlier, there does not appear to be a significant tomy: Does transhepatic puncture preclude a transperitoneal catheter difference in the rate of bile peritonitis associated with the route? J Vasc Interv Radiol 2:543-547, 1991 10. Maher MM, Kealey S, McNamara A, et al: Management of visceral transhepatic and transperitoneal routes. However, additional interventional radiology catheters: A troubleshooting guide for inter- complications that tend to be particular to the transhepatic ventional radiologists. Radiographics 22:305-322, 2002 approach include pleural contamination, arteriovenous fis- 11. Fache JS: Interventional radiology of the biliary tract: Transcholecystic tula formation, liver abscess, hemobilia, and liver hemor- intervention. Radiol Clin North Am 28:1157-1169, 1990 12. Laméris JS, van Overhagen H: Imaging and intervention in patients rhage.11 Nevertheless, these complications are very rare. with acute right upper quadrant disease. Baillieres Clin Gastroenterol 9:21-36, 1995 13. Boggi U, Di Candio G, Campatelli A, et al: Percutaneous cholecystos- References tomy for acute cholecystitis in critically ill patients. Hepatogastroenter- 1. van Sonnenberg E, Wittich GR, Casola G, et al: Diagnostic and thera- ology 46:121-125, 1999 peutic percutaneous gallbladder procedures. Radiology 160:23-26, 14. Welschbillig-Meunier K, Pessaux P, Lebigot J, et al: Percutaneous cho- 1986 lecystostomy for high-risk patients with acute cholecystitis. Surg En- 2. Kavanagh PV, van Sonnenberg E, Wittich GR, et al: Interventional dosc 19:1256-1259, 2005 15. Davis CA, Landercasper J, Gundersen LH, et al: Effective use of percu- radiology of the biliary tract. Endoscopy 29:570-576, 1997 taneous cholecystostomy in high-risk surgical patients: Techniques, 3. Taylor S, Rawlinson J, Malone DE: Technical report: Percutaneous tube management, and results. Arch Surg 134:727-732, 1999 cholecystostomy in acute acalculous cholecystitis. Clin Radiol 45:273- 16. van Sonnenberg E, D’Agostino HB, Goodacre BW, et al: Percutaneous 275, 1992 gallbladder puncture and cholecystostomy: Results, complications, 4. Vatansev C, Belviranli M: Percutaneous cholecystostomy with locking and caveats for safety. Radiology 183:167-170, 1992 trocar: How I do it? Surg Endosc 17:162-163, 2003. Epub 2002 Sep 30 17. Mazzotta D, Mosca F: Percutaneous cholecystostomy for acute chole- 5. Ghahreman A, McCall JL, Windsor JA: Cholecystostomy: A review of cystitis in critically ill patients. Hepatogastroenterology 46:121-125, recent experience. Aust N Z J Surg 69:837-840, 1999 1999 6. Teplick SK: Diagnostic and therapeutic interventional gallbladder pro- 18. Hatzidakis AA, Prassopoulos P, Petinarakis I, et al: Acute cholecys- cedures. Am J Roentgenol 152:913-916, 1989 titis in high-risk patients: Percutaneous cholecystostomy vs conser- 7. Akhan O, Akinci D, Ozmen MN: Percutaneous cholecystostomy. Eur J vative treatment. Eur Radiol 12:1778-1784. Epub 2002 Feb 21, Radiol 43:229-236, 2002 2002