Image-Guided Percutaneous Cholecystostomy Review PDF

Irish Journal of Medical Science (1971 -) https://doi.org/10.1007/s11845-021-02655-7 REVIEW ARTICLE Image‑guided percutaneous cholecystostomy: a comprehensive review Shayeri Roy Choudhury1 · Pankaj Gupta1 · Shikha Garg1 · Naveen Kalra1 · Mandeep Kang1 · Manavjit Singh Sandhu1 Received: 27 Mar...

Irish Journal of Medical Science (1971 -) https://doi.org/10.1007/s11845-021-02655-7 REVIEW ARTICLE Image‑guided percutaneous cholecystostomy: a comprehensive review Shayeri Roy Choudhury1 · Pankaj Gupta1 · Shikha Garg1 · Naveen Kalra1 · Mandeep Kang1 · Manavjit Singh Sandhu1 Received: 27 March 2021 / Accepted: 13 May 2021 © Royal Academy of Medicine in Ireland 2021 Abstract Acute cholecystitis (AC) is a common emergency condition with severity ranging from mild to severe. Gallstones and critical illnesses are the common predisposing factors. Mild AC is primarily managed with medical therapy and early cholecys- tectomy. Moderate and severe AC require individualized treatment with a preference for early cholecystectomy. However, cholecystectomy may not always be feasible due to co-morbidities. Hence, this group of patients needs minimally invasive methods to drain the gallbladder (GB). Percutaneous cholecystostomy (PC) is the image-guided drainage of GB in the setting of moderate to severe AC. There are different approaches to PC. The technical aspects, success, and complications of PC as well as management of cholecystostomy catheter after the patient recovers from the acute episode should be thoroughly understood by the interventional radiologist. We present an extensive up-to-date review of the essential aspects of PC includ- ing indications, contraindications, techniques, and outcomes, including complications and success rates. Keywords Acute cholecystitis · Image-guided · Percutaneous cholecystostomy Introduction percutaneous cholecystostomy (PC) has long been used as a management strategy in patients with acute calculous or acal- Acute cholecystitis refers to the inflammation of the gallblad- culous cholecystitis who are at high risk for surgery as it is less der (GB) which can be precipitated by multiple causes, most invasive and is associated with lesser operative and anaesthe- common being gallstones. Other causes include critical ill- sia-related risks. It is an accepted modality of biliary drainage nesses and prolonged admission in the intensive care units. in patients with acute cholecystitis with moderate (Grade II) Acalculous cholecystitis is much more common than calculous or severe (grade III) disease according to the updated Tokyo cholecystitis in the setting of critical illness. Prolonged total 18 (TG18) guidelines. Other alternatives available for parenteral nutrition, shock, sepsis, surge in systemic inflam- non-surgical management of such patients are percutaneous matory cytokines, mechanical ventilation, hypovolemia, and transhepatic gall bladder aspiration, endoscopic naso-biliary dehydration are common causes in the critically ill patients drainage, and endoscopic ultrasound–guided transmural gall- [2, 3]. Diagnosis is often difficult leading to alarmingly high bladder drainage (EUS-GBD). EUS-GBD is a relatively new mortality rates in these patients, reaching up to 50% in some technically challenging procedure with relatively less clinical cases. Ultrasound plays a vital role in establishing the diagno- evidence. It is practiced by skilled endoscopists in high vol- sis of acute cholecystitis. Overdistended gallbladder, luminal ume centres. Recently, the indications for PTGBD have been debris, layered mural thickening, and pericholecystic fluid with expanded to include cholangitis, biliary obstruction, and as a or without gallstones are important findings on ultrasound. potential route for stone extraction and dissolution. The sonographic Murphy’s sign may be absent in critically ill patients. Percutaneous transhepatic GB drainage (PTGBD) or History * Pankaj Gupta [email protected] The first cholecystostomy was performed by a surgeon in Indiana, USA. However, the first image-guided chol- 1 Department of Radiodiagnosis and Imaging, Postgraduate ecystostomy was done much later in 1980 by Radder for Institute of Medical Education and Research, GB empyema in an elderly patient. Chandigarh 160012, India 13 Vol.:(0123456789)  Irish Journal of Medical Science (1971 -) can also be performed in cases not responding to conserva- tive management with IV antibiotics, analgesics, and anti- inflammatory medications, even after 3 days of treatment. Very elderly patients with acute cholecystitis may also benefit from the procedure especially those with underlying cardiovascular and neurological diseases. Emergency bedside ultrasound-guided PC is indicated in acalculous AC in the intensive care unit (ICU) as a part of management algorithm (Fig. 1A, B). Patients admitted to ICU with poly-trauma are also at increased risk of AC due to prolonged stay. These patients may benefit from upfront PC. Similarly, patients admitted in burns ward with extensive burns may also develop acute acalculous cholecys- titis due to prolonged total parenteral nutrition and severe dehydration; such patients have been successfully treated with emergent PC. Fig. 1  Indications for PC-acute cholecystitis. A Ultrasound (US) of Emphysematous cholecystitis is a potentially fatal type of acalculous acute cholecystitis with echogenic mural thickening and AC due to superadded infection by gas-producing organisms echo free lumen (arrow). B Axial contrast enhanced CT image show- ing mural thickening and pericholecystic fat stranding (arrow). C US (Fig. 2). It is seen commonly in elderly diabetic patients, of calculous acute cholecystitis with mural thickening (arrow) and more often in men. Emergency cholecystectomy is consid- calculus with posterior acoustic shadowing (dashed arrow). D Axial ered the standard of care; however, PC should be considered contrast–enhanced CT image showing mural thickening, calculus in as an alternative management strategy due to the risk of lumen, and pericholecystic fat fluid (arrow) complications. Indications AC in pregnancy is a rare condition occurring in 0.1% of patients. Traditionally, it is treated conservatively with Most commonly PC is indicated for AC in patients who analgesics and antibiotics and an interval cholecystectomy are at high risk for surgery due to underlying comorbidi- is preferred in the post-partum state. But sometimes due to ties (Fig. 1; Table 1). Cholecystectomy is the treatment of significant distress and pain associated with inflammation, choice in AC; however, in many patients, it is associated emergency PC can be performed with subsequent post-par- with high risk of complications from surgery or general tum cholecystectomy. anaesthesia [4, 8]. Surgery in the setting of severe AC is Hemorrhagic cholecystitis is a rare complication of AC frequently associated with immediate post-operative com- with unclear aetiology but sometimes associated with under- plications due to pericholecystic inflammation and loss of lying comorbidities such as renal disease, bleeding disorders the cleavage plane between GB and the liver. In such like haemophilia and von Willebrand disease, and prolonged patients, upfront PC serves as a useful procedure [10, 11]. It anti-coagulant use (Fig. 3). Surgery may not be feasible in Table 1  Indications of percutaneous cholecystostomy Gallbladder–related indications: 1. Calculous acute cholecystitis (severity grade II/III according to Tokyo guidelines) in patients with co- morbidities who are poor surgical candidates 2. Acalculous acute cholecystitis in critical ill/intensive care patients 3. Emphysematous cholecystitis 4. Hemorrhagic cholecystitis 5. Gangrenous cholecystitis 6. Acute cholecystitis in pregnancy 7. Gallbladder empyema 8. Gallbladder perforation Biliary indications: 1. Biliary decompression in cholangitis in patients with failed ERCP or PTBD 2. Trans-cholecystic biliary access for i.) Removal of gallstones, cystic duct stones, or common bile duct stones ii.) Biliary stenting or cholangioplasty iii.)Endoscopic cholecystoscopy 13 Irish Journal of Medical Science (1971 -) Fig. 3  Hemorrhagic cholecystitis in a patient of Von-Willebrand’s Fig. 2  Emphysematous cholecystitis. Axial contrast enhanced CT disease. US showing GB wall thickening with multiple varying den- showing multiple calculi in GB with air foci in lumen and surround- sity echoes in the lumen (blood products) ing fat stranding (arrow) such as stones, strictures, or masses who have failed ERCP many of these cases due to the impending risks and compli- or PTBD. It provides an effective bridge procedure to cations. Many patients are also treated conservatively with control sepsis and obstructive jaundice and gives a window antibiotics and withdrawal of anticoagulant medications with period to plan further interventions. interval cholecystectomy. However, in situations where there Transcholecystic biliary access through the percutaneous is inadequate response to conservative treatment and emer- catheter can also provide a route for long term and man- gency cholecystectomy cannot be performed due to bleeding agement of gallstones in patients who cannot undergo sur- tendency, PC may be performed as a temporary palliative gery due to medical conditions that preclude anaesthesia measure to alleviate the symptoms.. Contact litholysis using stone dissolving agents such GB perforation is a grave condition with increased mor- as Methyl tert-butyl ether (MTBE) has been successfully bidity and mortality specifically in the elderly age group performed in high-risk patients. patients (Fig. 4). It can lead to devastating complications PC can also aid in other biliary interventions in certain such as intra-abdominal abscess, peritonitis, sepsis, and situations. Although the preferred route for percutaneous shock. Perforations can present in both acute and sub-acute access to biliary ducts is transhepatic through the intra stages. PC is a lifesaving procedure in these cases. hepatic biliary radicles, if that access is not available or Although much rarer in the paediatric population, GB perfo- feasible due to any reason, transcholecystic route may be ration is sometimes seen associated with enteric fever, severe used. The reasons can be intrahepatic stones, diffuse sepsis, or post trauma. PC has been successfully performed in few select paediatric cases [21, 22]. Iatrogenic perforation is a rare complication after percuta- neous liver biopsy. Literature evidence shows that iatrogenic GB perforation can be treated effectively with PC and unnec- essary surgical intervention can be avoided. The use of PC is expanding for biliary decompression in patients with pancreatitis and cholangitis (Fig. 5) who cannot undergo endoscopic retrograde cholangiopancreatog- raphy (ERCP) or percutaneous transhepatic biliary drain- age (PTBD). Data demonstrates favourable results in terms of decompression of the biliary system, reduction in Fig. 4  GB perforation. A US image showing diffuse GB wall thick- serum bilirubin, and alkaline phosphatase levels, as well as ening, pericholecystic fluid (arrow), and echogenic foci outside the lumen (dashed arrow), suggestive of perforation. B Axial CT showing improved patient condition. PC is also effective in patients air and hyperdense calculi containing collection in the right lobe of with acute cholangitis due to distal bile duct pathologies liver (arrow) 13  Irish Journal of Medical Science (1971 -) Table 2  Contraindications of percutaneous cholecystostomy Absolute contraindications: None Relative contraindications: Coagulopathy (Platelet count < 50,000/mm3 or INR > 1.5) Allergy to iodinated contrast Ascites Contracted gallbladder with multiple stones Fig. 5  Pancreatitis with biliary complication. MRI abdomen T2 TRUFI A coronal and B axial showing GB wall oedema and fluid (white arrows). Pancreatitis with peripancreatic fluid collection is INR should be < 1.5. Liver function tests should seen in anterior pararenal space (dashed arrow) be ordered. Broad spectrum intravenous antibiotics namely cephalosporins and aminoglycosides should be started to cover bacteria such as E. coli, according metastatic liver disease, non-dilated intra hepatic biliary to the hospital policy. Patients who are being planned radicles, or extensive cystic liver disease. The pre-requisite for PC the following day should be kept fasting over- for access to common bile duct in such cases is a patent night to adequately distend the gallbladder; however, cystic duct. The same can be confirmed by a percutaneous most patients undergoing the procedure are on parenteral cholecystogram. Through the transcholecystic route, vari- nutrition. ous procedures such as biliary stenting and cholangioplasty For technical planning of the procedure, the available may be performed. Newer techniques such as chol- cross-sectional imaging is evaluated to decide the pre- ecystoscopy using flexible or rigid endoscopes have been ferred approach for PC-transhepatic or transperitoneal attempted with some success to aid in removal of stones routes (Fig. 6). Majority of PC procedures are preferred by using electrohydraulic lithotripsy, ultrasonic lithotripsy, through the transhepatic route due to better anchoring of or nitinol baskets (similar to ureteric stone removal). the catheter and lesser chance of intra peritoneal bile leak Technical limitations include narrow or tortuous cystic duct as the GB fossa does not contain any peritoneal reflec- with multiple angulations or tight valves of Heister. tion. There is also the added advantage of early tract maturation due to pericatheter fibrinous deposition within the liver parenchyma. However, in some situations, Contraindications trans-peritoneal route may be preferred, such as coagu- lopathy or diffuse liver diseases, as it avoids liver capsular No absolute contraindications to PC have been documented puncture which may lead to hematoma or bleeding. Fur- so far (Table 2). Relative contraindications include thermore, transperitoneal approach is preferred if future coagulopathy. PC may be performed after correction with interventions are anticipated through the cholecystectomy platelet and fresh frozen plasma infusions to achieve a plate- tract. Risks with transhepatic approach include inadvertent let count of > 50,000 and an INR of < 1.5. Ascites is also pneumothorax during puncture or tract dilatation or hemo- considered as a relative contraindication, but percutaneous biliary fistula. Recent studies have shown that short- and drainage of perihepatic ascitic fluid can be easily performed long-term outcomes of both the routes are comparable; prior to PC. Recent studies have also shown that compli- therefore, the shortest and safest route should ideally be cation rates in PC are similar in patients with and without chosen [35, 36]. The most important factor to consider is ascites. GB with multiple stones may preclude success- the operator’s personal experience. ful percutaneous drain placement. Technique Procedure Pre‑procedural planning Routinely, only light sedation and analgesia with local anaesthesia is required for PC. Pre-procedural administra- Complete hemogram with platelets and leukocyte count is tion of intravenous tramadol along with an anti-emetic is routinely performed for patients being considered for PC. an effective analgesic. Local instillation of 2% lignocaine In addition, coagulation profile with prothrombin time with or without adrenaline is into the subcutaneous and and international normalized ratio (INR) is also obtained. peri-hepatic plane in the intended site for intervention is The platelet count should be more than 50,000/µl, and used. The approach is preferred to be right subcostal in the 13 Irish Journal of Medical Science (1971 -) Fig. 7  US-guided PC procedure. A US demonstrating transhepatic route with guidewire in GB lumen (arrow). B Pigtail catheter tip seen in GB lumen (arrow) small amount of fluid is done to obtain sample for analysis and culture. Following this, the stiff guidewire is introduced Fig. 6  Schematic diagram demonstrating trans hepatic and trans peri- under visualization. When the guidewire is visualized suf- toneal approaches for PC under US guidance ficiently within the lumen, serial dilatation of the percutane- ous tract is performed up to the size of the pigtail catheter. The pigtail catheter is then introduced under guidance. A anterior axillary line; however, if intercostal route must be dilute contrast cholecystogram is performed to visualize the used, then care should be made to avoid the neurovascular opacified gallbladder and to ensure all the draining holes bundle running in the inferior rib notches. Generally, for a of the catheter are within the lumen, if fluoroscopy is used. transhepatic route, the intercostal approach is preferable as Care should be taken not to introduce excessive iodinated the catheter is more secure within the rib spaces. contrast due to fear of chemical cholangitis, or aggravation The modality most commonly used for PC in the inter- of sepsis. Following this secure skin sutures are applied, and vention suite is the combination of ultrasound and fluor- a draining bag is attached. oscopy (Figs. 7 and 8). CT guidance may be required in A modified single puncture technique has also been patients with poor sonographic visualization of GB, insuf- described, where initial puncture into the distended GB is ficiently distended GB, emphysematous cholecystitis, bowel performed with an 18-gauge needle, followed by insertion interposition between organ and skin, or in obese patients. of a stiff guidewire. An 8F single puncture pigtail catheter is Bedside PC in the intensive care is performed using ultra- introduced over the guidewire into the lumen, thus avoiding sound guidance only [37, 38]. Limited data has shown that the need for serial dilatation. CT-guided PC has a greater success rate than ultrasound. But the modality of guidance for PC is purely based Post‑procedure care on the preference of interventional radiologist. Both the Seldinger and the trocar methods are suitable for Patient vitals are monitored for at least 4–6 h (most of the PC, Seldinger method being used more commonly. It patients are already under intensive care). Adequate intra- is associated with less procedural pain. Theoretically trocar venous hydration is ensured with continuation of the rec- technique is associated with more bleeding and subsequent ommended antibiotic regimen. Health care worker or the hemobilia. In the author’s institution the Seldinger’s tech- nique with a transhepatic route is generally preferred. The materials used are an 18-gauge bevelled edge access needle, stiff guidewire, serial fascial dilators, and 6–10 Fr locking pigtail catheters. A convex ultrasound probe of 2-5.5 MHz is ideal for visualization of both the desired nee- dle pathway and the distended gallbladder. Colour Doppler assessment to visualize any major hepatic or portal vessels that could be within the intended route is useful to prevent accidental vascular injury. Under ultrasound or CT guidance, the route of the drain is planned, and after administration of Fig. 8  Adequately positioned PC catheter. Axial CECT (A) and cor- local anaesthesia, needle is introduced with its tip positioned onal CECT (B) abdomen showing well positioned catheter in GB within the gallbladder lumen. A diagnostic aspiration of a lumen 13  Irish Journal of Medical Science (1971 -) patient’s are attendant explained the catheter care to prevent Table 3  Complications of percutaneous cholecystostomy dislodgement of the catheter. Pericatheter hygiene and regu- Minor complications: lar dressing is also explained. Catheter is gently flushed with 1. Pain (very common) 5–15 ml of sterile saline every 12 h to prevent clogging by 2. Catheter dislodgement (common) debris and bile salts. 3. Mild hemobilia Moderate to severe complications: 1) Severe hemorrhage and hemobilia (arterial or venous) Complications 2) Biliary leak causing a) Peritonitis As PC is considered a lifesaving procedure which is per- b)Sepsis formed for severely debilitated patients who cannot tolerate c) Biloma formation surgery, the complications due to PC may be aggravated by 3) Pleural and pulmonary complications the underlying disease. In addition, the complications may a) Pneumothorax be missed or overlooked at the initial stage due to associated b) Pneumo-biliary fistula illness or the altered mental status of patient. In fact, surgi- c) Biliary effusion cally unfit or severely moribund patients are more likely to d) Pneumonia encounter post procedural complications. 4) Bowel perforation Complication rates are widely variable in available lit- 5) Vasovagal syncope with hypotension and bradycardia erature, ranging between 0 and 50% in different studies [10, 42–44]. Complications can be divided into minor, moderate, and major (Table 3). Most of the complications can be man- aged conservatively; however, depending upon the complica- orally or intravenously. In cases with intractable pain, opioid tion, sometimes surgical or interventional procedures may analgesics along with sedatives may be required. be warranted. Other minor complications include minor bleeding which may be procedure related or due to trauma to the hepatic vas- Minor complications culature in trans-hepatic route. As GB wall is inflamed and friable, during procedure, it is not uncommon to encounter Most common complications are minor and easily man- mild hemobilia. However, monitoring of the catheter out- aged. The commonest complication is catheter dislodge- put, patients’ vital parameters, and hemogram is essential ment which is reported in up to 80% in certain studies. as persistent hemobilia could indicate more serious vascular Catheter dislodgement is relatively more commonly in PC trauma. In addition, the absence of hemobilia in a patient than other abdominal drainage catheters. The likely cause is who presents with significant hemogram drop and symptoms respiratory movement and movement of the ribs that cause of hypovolemic or hemorrhagic shock does not rule out sig- slow displacement of the catheter. The GB also periodically nificant hepatic vascular injury. contracts and distends in response to feeding or fasting state Theoretically, risk of haemorrhage is more in patients which can aid in instability. As many patients are admitted with underlying coagulopathies such as platelet dysfunc- in intensive care with altered mental status, there is a ten- tion or deranged INR values. Coagulopathy is common dency to inadvertently pull out the catheter. The intercostal in patients with disseminated sepsis, due to antiplate- transhepatic approach is associated with lesser rate of cath- let and anticoagulation medications (heparin, warfarin, eter displacement. Loop locking pigtail catheters are also aspirin etc.), and those with inborn factor deficiencies. used to prevent displacement. A catheter with no output may Studies on the rates of hemorrhagic complications in require fluoroscopic or sonographic evaluation to confirm coagulopathic patients are scarce, but limited data has position and remove catheter kinks or clogging, if any. In shown that the complication rates in both populations are some cases, re-insertion may be required. comparable. Pain, either in the right hypochondrium or diffusely in the abdomen, is also quite common. The pain may be mul- Moderate to major complications tifactorial and is more in patients with cholangitis, pancrea- titis, or obstructive jaundice than in patients with AC. Generally, small amount of procedure-related haemorrhage Catheter site pain is also seen likely due to close relation of is not unexpected in the setting of GB wall inflammation the catheter to the intercostal neurovascular bundle. In most (Fig. 9). Hemorrhagic complications occur in 2.2% of PC cases, pain is a minor complication and easily managed by procedures. Haemoglobin fall > 1 g/dl is usually con- analgesic and anti-inflammatory medications given either sidered a moderate complication, and the patient should be 13 Irish Journal of Medical Science (1971 -) monitored closely for possibility of intra-abdominal bleed. that all the draining holes of the tube are located within Significant (more than 4 points) haemoglobin drop after the lumen. Management of biliary leak requires manage- the procedure rarely occurs and is alarming as it may indi- ment of the sepsis and peritonitis. Catheter may need to be cate underlying active bleed. Such a complication may repositioned to a more secure intra luminal location in GB. require urgent CT angiography to locate the site of bleed- Additional intra-abdominal drains may be required to drain ing (venous, arterial, or hepatic sinusoidal). In case of arte- the ascites or biliomas [44, 51]. rial bleeding, a digital subtraction angiography along with Trans-hepatic route through the intercostal spaces carries embolization of the offending artery may be warranted to a risk of pneumothorax if the needle accidentally pierces the stop the bleeding. In recalcitrant cases or those with massive pleura. Minimal pneumothorax localized to the costophrenic intra-abdominal bleed, emergency laparotomy may be indi- sulcus may go unnoticed. Significant pneumothorax may result cated. However, massive haemorrhage requiring repeated in sudden onset tachypnea, fall in oxygen saturation, and chest blood transfusions or surgical intervention is exceedingly pain and requires immediate chest tube placement. Pneumo- rare. A case significant haemorrhage following PC which thorax can be easily detected during procedure by fluoroscopy. was managed with angioembolization of the cystic artery has Persistent pneumothorax along with bile leak can lead to bilio- been described. Signficant haemorrhage due to portal pleural fistula, bilio-pneumothorax, empyema, or pneumonia. vein trauma requiring endovascular management has also Bowel wall perforation can very rarely occur if a bowel been reported. segment is interposed between the GB and abdominal wall. Bile leak in the immediate post procedure period It can be avoided by careful review of pre-procedural imag- (0–7 days) can be a minor complication leading to peri- ing along with dedicated ultrasound to ensure the intended catheter skin excoriation due to chemical irritants in bile course of PC is clear of any bowel loop; however, there is salts. However, significant bile leak is considered a major some available data on accidental colon or small bowel per- complication and can cause biliary peritonitis and sepsis foration. Inadvertent colonic perforation due to technical with formation of intra-abdominal bilioma. A system- error has been reported which required laparotomy. atic review of 1913 patients reported biliary complica- Another case small bowel perforation has also been reported tion–related mortality to be around 3.6%; however, it is in literature which resulted in fulminant peritonitis requiring uncertain how many are directly procedure related. emergency laparotomy. Biliary leaks are more common in the trans-peritoneal Other moderately severe complications that can occur approach. A multi-centre analysis of post PC outcome during the procedure are hypotension, bradycardia, vaso- has listed bile leakage as the most common complica- vagal syncope, and pneumonia; however, data regarding tion requiring intervention. Biliary leak can be their incidence is scarce and inconsistent in literature. prevented by using continuous ultrasound and fluoro- scopic guidance while tube placement and ensuring Delayed complications A study reported a high incidence of cystic duct or com- mon bile duct stones in patients with prolonged PC. Post-operative sub-hepatic, GB bed, and sub-phrenic abscesses have also been reported with a higher inci- dence (approximately 23%) in patients who undergo interval cholecystectomy following PC. This can be attributed to the infection and inflammation in the peri- hepatic region which leads to infected fluid collections around the post-operative bed. These collections or abscesses can contribute to significant morbidity and even mortality in the post-operative period and may require interventional drainage or surgical re-exploration on a case-to-case basis. A rare complication that may be seen in few patients is Fig. 9  PC complications. Axial CECT abdomen (A, B, C, D) show- cholecystocutaneous or cholecystohepatic fistula, which ing pigtail catheter in GB lumen with hyperdense contents suggestive may cause persistent biliary leakage from the PC site after of haemorrhage (A; white arrow), cholangitic abscesses in right lobe the catheter is removed due to a fistulous tract between the (C, D, dashed arrows), and intra hepatic biliary dilatation (D, black arrows) 13  Irish Journal of Medical Science (1971 -) GB and skin. Alternatively, there can be an abscess forma- been reported in up to 100% of procedures in literature. tion within the subcutaneous abdominal wall when the skin Favourable clinical outcomes are reported in more than 90% wound heals causing a fluctuant, possibly tender swelling patients in most studies [43, 50, 61, 62]. [54, 55]. Definitive management of such a complication is Early response is suggested by resolution of fever, tachy- to perform cholecystectomy with drainage of the collection cardia, normalization of leukocyte counts, reduction in or closure of the fistulous tract. inflammatory mediators, and resolution of sepsis. Early Delayed bile leaks into the peritoneal cavity after removal outcomes for both trans-peritoneal and trans-hepatic routes of the PC catheter may also occur, which can be explained of PC are similar; therefore, it is recommended that the route by the iatrogenic rent in the GB wall. It is theoretically more can be chosen according to the interventional radiologist’s common in the trans-peritoneal route. Although mostly comfort and discretion. In the decision to perform PC insignificant, sometimes significant bile leak can occur in versus continue conservative management of patients with up to 3% of cases and cause biliary peritonitis. Theoretically, AC, it has been shown that early PC in even mild-to-mod- performing a cholecystogram to assess patency of the cystic erate AC has favourable outcome in terms of resolution of duct and CBD along with a tractogram to delineate any small fever and lesser long-term complications. site of leak can prevent significant bile leak. Long-term outcome of the procedure depends upon the Recurrent cholecystitis is a relatively common occurrence eventual management of the patients and the fate of the PC in patients who have PC but do not undergo interval cholecys- catheter. The possible strategies are one of the following: - tectomy. Recurrence can occur in 25–40% cases. The timing of recurrence is variable and unpredictable, reported 1. Removal of PC once the clinical features subside and from median period of 65 days to even after 1095 days. biochemical investigations normalize with no further However, recurrent cholecystitis commonly occurs within surgical intervention. 1 year of PC. Early recurrence of cholecystitis is not uncom- 2. Early or delayed laparoscopic/open cholecystectomy fol- mon within the first two weeks and can often occur within the lowing PC in patients suitable for surgery. same hospital stay. Patients with calculous AC and empy- 3. Destination PC with long term or lifelong indwelling ema have a higher risk for recurrence. PC in the setting catheter of choledocholithiasis and hepatobiliary malignancies is also associated with recurrent episodes of AC. A systematic review advocated that tube cholangiogram to check patency of Group 1: Removal of PC after resolution the cystic duct and CBD may prevent recurrence. Another of cholecystitis and no further surgical study stated that a trial of PC catheter clamping for 1–2 weeks intervention prior to permanent removal should be performed to check for recurrence of biliary symptoms. Overall, the risk of Removal of the PC tube is advisable as a long-term cath- gallstone-related recurrent cholecystitis has been reported to be eter comes with its own complications and associated risk similar in PC and conservative management. Cholecys- of infection in already moribund patients. The timing tectomy should be performed in the same admission wherever of PC tube removal after resolution of cholecystitis varied possible to avoid re-admissions. between 2 and 193 days according to a systematic review, To summarize, mortality rates from PC-related com- and there appears to be no significant difference in overall plications vary widely due to the myriad of associated co- outcome depending on the duration of PC. It is how- morbidities in the patient profiles. It is difficult to postulate ever recommended that the PC tube should only be removed exact mortality rates due to long follow-up duration, mul- after the tract has sufficiently matured and cholecystogram tiple hospital admissions, and underlying illnesses. In such reveals a patent cystic duct. Removal of catheter within patients, 30-day mortality rates have been described to be 1 week is usually not recommended due to risk of biliary around 3.6% due to biliary complications, and approximately sepsis and recurrent disease. The duration for tract 0.36% as directly related to the procedure itself in a system- maturation is between 3 and 6 weeks; therefore, it may be atic review. inadvisable to remove the tube prior to this period. A trial of clamping of PC catheter for 1 week should be under- taken to look for recurrence of biliary symptoms. Success- ful clamping with no fresh symptoms has shown to reduce Outcomes the risk of recurrent AC. The catheter should ideally be removed under fluoroscopic guidance, by first inserting a PC is universally considered to be a low-risk and safe pro- stiff guidewire to straighten out the tip of the pigtail, fol- cedure for patients with both calculous and acalculous AC lowing which the entire system can be withdrawn gently. As who are considered unfit for surgery. Technical success has the definitive treatment for AC is cholecystectomy, there is 13 Irish Journal of Medical Science (1971 -) a risk of recurrent AC in this category of patients, and many complications, recurrence of biliary disease, and require- may require eventual cholecystectomy or repeat PC [62, 67]. ment for re-intervention (surgical, radiological, or lapa- It is advisable to weigh the risk of surgical complications roscopic) were significantly higher in patients with PC as versus the risk of recurrent episodes of biliary colic in such compared to laparoscopic cholecystectomy group. Duration patients. of hospital stay was also significantly longer. Mortality rates did not vary significantly between the groups. However, the results of the trial were applicable only to patients with an APACHE II score of 7 to 14, and further multicentric Group 2: Early or delayed laparoscopic/open studies are warranted to compare the outcomes of sur- cholecystectomy following PC gery and PC in more severely ill patients. Advancement in anaesthesia techniques, improvement in critical care, and This group includes patients who undergo laparoscopic or post-operative medicine, even grade II and grade III AC open cholecystectomy which may either early or delayed. may benefit from emergency cholecystectomy, who were The optimal timing of surgery is debatable. However, stud- previous thought to be at high risk for surgery and required ies show that an ideal time to remove the diseased GB is emergency PC with delayed cholecystectomy. between 7 and 26 days after PC [68, 69]. Some studies have shown increased risk of complications when surgery was performed within 4 weeks of PC [70, 71]. Another study reported higher rate of complications related to dislodge- Newer alternatives ment of PC catheter in the group undergoing surgery after 10 days; however, there was no significant difference in over- EUS-GBD is an upcoming alternative to PC in patients with all outcome between patients undergoing cholecystectomy high risk for surgery, and it has the advantage of internal drain- before or after 10 days. It is therefore uncertain whether age. Preliminary data shows that there are fewer complications, the timing of cholecystectomy has any bearing on the mor- lesser recurrence of biliary symptoms, and no catheter related bidity or mortality of patients undergoing PC. problems with EUS-GBD [77–80]. Mean duration of hospital stay is also reported to be lesser in EUS-GBD as compared to PC. Technical success rates for both procedures are how- ever similar. The use of lumen-apposing metallic stents Group 3: Destination PC (LAMS) has also shown promising results. There is also scope for internalization of PC with cholecystoenterostomy Due to low risk associated with PC, there is a tendency to stent, which can be done under EUS guidance. With suc- overuse the procedure for patients at high risk for surgery. cessful internalization and LAMS placement, the patient will This has led to reduced incidence of interval cholecystec- have an unobstructed internal biliary drainage system which tomy, and placement of a long-term destination tube. How- may prevent further attacks of cholecystitis. It is an attractive ever, in the era of enormous development in the field of long-term treatment option in patients who continue to be unfit surgery and anaesthesia, surgeries can now be performed for surgery even after PC placement. Further trials and prospec- with relatively minimal complications on patients who were tive studies are required to further elaborate on the procedure earlier deemed unfit. Therefore, it is prudent to consider the and its outcomes. A single-centre prospective trial comparing possibility of cholecystectomy in every patient instead of endoscopic naso-gallbladder drainage and PC is underway to destination PC. provide clinical evidence on the comparison of outcomes of Masrani et al. proposed that after PC placement, the algo- both the procedures. rithm must be tailored according to present of calculous or acalculous AC. A cholecystogram is recommended after 2 weeks to look for cystic duct calculi, biliary stones, and obstruction. Patients with stones who are surgical candidates must be offered the option for the same, and non-surgical Conclusion candidates should undergo percutaneous stone extraction. Acalculous cholecystitis warrants waiting for 6 to 8 weeks PC is a well-established and safe procedure for moderate to followed by trial of clamping the catheter. 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