Percutaneous Cholecystostomy: Evidence-Based Current Clinical Practice

Abstract

The role of percutaneous cholecystostomy (PC) in the management of acute cholecystitis and cholangitis is outlined in the revised 2013 Tokyo Guidelines. These two emergencies constitute the vast majority of PC performed today for therapeutic purposes, and research has repeatedly shown the utility of PC in these conditions. PC is typically employed in the management of critically ill patients who are not surgical candidates. Indications and contraindications to PC are reviewed. Additional innovative applications of PC have been developed since it was first described in 1980. These include biliary drainage, dilation of biliary strictures, and stenting of the biliary tree including the common bile duct. Special consideration must be given to the patient selection criteria when deciding who can benefit from PC. Patient comorbidities can also influence the PC technique employed. Both transhepatic and transperitoneal approaches have distinct advantages and disadvantages. The technical success rate for PC is 95 to 100% and the complication rate is extremely low. Most complications are minor.

Keywords: cholecystitis; gallbladder; gallstones; interventional radiology; percutaneous cholecystostomy.

Fig. 1

Computed tomography of (a) axial image of an unremarkable gallbladder (open arrow) with normal wall thickness, no pericholecystic fluid, and no adjacent fat stranding; (b) coronal image of acute acalculous cholecystitis with wall thickening, pericholecystic fluid, and fat stranding; the dotted arrow indicates an adequate transhepatic window for percutaneous cholecystostomy (PC); (c) axial image of a decompressed gallbladder after adequate placement of a drainage catheter (small arrow) status post–PC.

Fig. 2

Ultrasound of (a) acute acalculous cholecystitis with gallbladder wall thickening (white arrow) and pericholecystic fluid in this patient with a positive sonographic Murphy sign; (b) longitudinal view of the inflamed gallbladder and potential transhepatic route (dotted arrow) for percutaneous cholecystostomy access.

Fig. 3

Fluoroscopic image of a cholecystogram after technically successful percutaneous cholecystostomy. A newly placed 8F all-purpose drain (APD) is seen within the right upper quadrant (open arrow), placed under ultrasonographic guidance. Contrast is confirmed to flow through the cystic duct, common bile duct, and into the duodenum without obstruction.