Cholecystostomy

Cholecystostomy finds its application when the patient has cholecystitis and is not a good candidate for surgery. Some indications include: • Critically ill patients that are clinically unstable to tolerate surgical cholecystectomy • Patients resistant to medical management (no clinical improvement after at least 72 hours of medical treatment) • Severe acute cholecystitis (Grade III acute cholecystitis according to the Tokyo Guidelines) == Contraindications ==

Contraindications to cholecystostomy include: • Coagulopathy • Interposition of gastrointestinal contents between the skin and the gallbladder (increases the risk of organ perforation) • Biliary peritonitis • Ascites == Percutaneous cholecystostomy ==

Approach Percutaneous cholecystostomy is performed under sedation and guided by ultrasound (US) or computed tomography (CT) imaging. Some advantages include: fewer bile leaks due to the liver abutting against the gallbladder and acting as a tamponade, lower risk of bowel perforation, and better outcomes in patients with severe ascites. The patient's clinical status, medications, and laboratory values (i.e. white blood cell count, coagulation studies, inflammatory markers, anticoagulation therapy, etc.) are reviewed to ensure the patient is stable for the procedure. Major complications, although rare, encompass sepsis, significant hemorrhage, pneumothorax, and bowel injury. Studies have shown that premature removal (before 21 days) is associated with a higher incidence of bile leaks. Once the cholecystitis is resolved and adequate time has passed for tract maturation, a clamp trial can be conducted for 24 hours to assess drainage from the gallbladder. If the patient passes the clamp trial (minimal to no drainage after unclamping), the tube is removed. Future management consists of performing a cholecystectomy to prevent future episodes of cholecystitis once the patient is stable for surgery. == Endoscopic cholecystostomy ==

An alternative to the percutaneous cholecystostomy is to use the endoscopic route. There are 2 primary techniques: endoscopic transpapillary gallbladder drainage (ET-GBD) and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD). These techniques are considered when the patient is a poor candidate for surgical cholecystectomy but can tolerate anesthesia for an endoscopic procedure and does not have a gallbladder perforation. Endoscopic Transpapillary Gallbladder Drainage This procedure is performed during an endoscopic retrograde cholangiopancreatography (ERCP). The cystic duct is cannulated and a plastic stent is deployed to relieve the blockage and allow for drainage. ET-GBD can be considered when the patient is already undergoing an ERCP for another medical condition (i.e. choledocholithiasis). Some drawbacks include an increased risk of pancreatitis from the ERCP procedure and a lower success rate compared to EUS-GBD or percutaneous cholecystostomy, particularly when there is evidence of cystic duct obstruction (i.e. stones, adhesions, strictures, cancer, or other masses). Endoscopic Ultrasound-guided Gallbladder Drainage EUS-GBD allows for internal drainage by placing a lumen-apposing metal stent (LAMS) into the gallbladder from either the stomach or the duodenum. The procedure involves using a cautery-powered LAMS to puncture through the gastric wall and enter the gallbladder. Two flanges on either side of the LAMS are deployed, tethering the stent on the inside walls of the gallbladder and gastric lumen. An important consideration is that the gallbladder must be within 10mm of the gastric puncture site. EUS-GBD is a good option for patients who are unlikely to undergo a future surgical cholecystectomy. It may also be used in patients with a cystic duct occlusion, or a pre-existing uncovered metal biliary stent. Some advantages include a high success rate with few complications and a reduced need for reinterventions. The primary drawback is the risk of stent occlusion with food or gastric contents. This risk is lowered when entering through the duodenum. EUS-GBD also complicates a future surgical cholecystectomy because the patient's anatomy is modified, requiring an additional repair of the choleycystoenteric fistula. == See also ==