Gallbladder drainage and cysticduct stenting

RAD Magazine, 42, 498, 13-15

Dr Rehan Abdul-HalimSpecialist registrar clinical radiology

Dr Frederick LeeConsultant radiologist

Sheffield Teaching Hospitalsemail: rehan.abdulhalim@gmail.com

BackgroundAcute cholecystitis (AC) is one of the commonestpresentations to the surgical ward in developedcountries.1 Clinical features, blood analysis andimaging usually lead to an early diagnosis andprompt initiation of antibiotic and supportivemedical therapy. Although the clinical course isoften self-limiting, complications related to gall-bladder perforation, fistulae formation and dis-seminated sepsis can occur. The currentmanagement guideline for AC is cholecystectomyduring the acute admission where possible, typi-cally within 72 hours.2

In those with a delayed presentation many surgeonsadvocate postponing the operation for six weeks whichreduces the complexity of the procedure related to adhesions.Similarly those patients who are acutely decompensated sec-ondary to the sepsis may go on to have a delayed cholecys-tectomy; these patients can be stabilised with medicaltherapy with or without an external gallbladder drain.3

There is a further cohort of usually elderly patients who,because of co-morbidities, will never be able to undergo acholecystectomy. These patients present a challenge as theyare at risk of recurrent episodes of AC, particularly if gall-stones are present.4 Long-term internal or external drainageof the gallbladder is a possible management plan for thisgrowing subgroup of patients.

DiagnosisClinical presentationTypical presentation includes an acute history of right upperquadrant or epigastric pain, nausea, vomiting and fever. Onexamination a positive Murphy’s sign (pain to deep palpationin the subcostal area on inspiration) has a specificity of 79%-96% for acute cholecystitis.5 A previous medical history ofgallstones, biliary strictures and/or biliary stenting increasesthe likelihood of AC.

Blood testsAlthough no specific blood test exists for AC, the presenceof infection and inflammation denoted by a raised white cellcount and C-reactive protein respectively are extremely use-ful markers both for supporting the diagnosis and assessingits severity. In addition, renal and liver function tests includ-ing a clotting profile help assess the general status of thepatient.

ImagingThe most useful first line imaging investigation in suspectedAC is ultrasound (US).6 Figure 1 shows some of the typicalfindings on US which include the following:• Distended gallbladder• Thickened gallbladder wall >4mm• Debris within the gallbladder• Stones within the gallbladder, cystic duct or common bile

duct• Fluid/abscess around the gallbladder• A positive sonographic Murphy’s sign.

Computerised tomography (CT) imaging of the abdomenand pelvis with or without intravenous contrast is seldomrequired to diagnose AC. CT can be useful in identifyingsome of the complications of AC such as perforation and fis-tulae formation (figure 2).

ManagementFormal guidelines on assessing the severity of AC have beenpublished and these provide an important role in determin-ing the most appropriate treatment option for each patient.7

As described, an in-patient cholecystectomy in the acutephase is regarded as the preferred treatment option. For theremainder of this article we will concentrate on thosepatients that may require gallbladder drainage in the formof image-guided cholecystostomy as part of their manage-ment plan. These patients fall into three broad categories:• Late presentation• Acutely decompensated patients• Multiple co-morbidities.

Ideally the first two groups of patients will go on to havean interval cholecystectomy procedure, usually about sixweeks after the acute presentation. These patients will beoptimised with medical management in the interim; somewill also require gallbladder drainage depending on theseverity of the AC and their response to antibiotics, fluidsupport etc. For these patients a cholecystostomy is indicatedas complications related to external drainage will be minimal– the drain will stay in place for a short time period only.

A cohort of patients with multiple co-morbidities isunlikely to be well enough to undergo surgery despite thebest medical support. This last group of patients provide thegreatest challenge in the management of AC. Patients withgallstone related AC are at risk of recurrent episodes and,although most cases will be self-limiting, the possibility ofcomplications must be borne in mind. The pre-existing ill-nesses may also reduce the chances of recovery from thesecomplications or at least increase the time to recovery. Apermanent minimally invasive cholecystostomy is a viablemanagement option in these patients. However, long-termexternal drainage, particularly in elderly patients, can beproblematic and this select group of patients may benefitfrom internal biliary drainage such as that offered by a cys-tic duct stent.

External drainageThose patients requiring a cholecystostomy will invariablyhave one placed by a radiologist using US guidance. CTguided drainage is possible but is more time consuming andcumbersome and seldom employed.

Patient preparation includes a recent blood profile (fullblood count and clotting screen), allergy status and consent.

Local practice varies but in our institution we require aplatelet count of above 50 x 109/L, haemoglobin above 9g/dLand an INR below 1.4. The presence of ascites is a relativecontraindication to cholecystostomy as the risk related tobleeding is increased. These patients can have an asciticdrain placed initially and proceed to cholecystostomy at alater date. Patients do not have to be kept nil by mouth forthis procedure. Consent must include the risk of the follow-ing:• Pain/discomfort• Bleeding• Infection• Perforation of bowel• Pneumothorax• Failure.

Once the patient has been adequately prepared, the radi-ologist using US will identify the safest route into the gall-bladder. Two possible methods can be employed, thetrans-hepatic route which involves going through the liver,and the trans-peritoneal route which avoids the liver. Thepractice in our institution is to proceed with the route thatgives the easiest access to the gallbladder. Advocates of thetrans-hepatic approach cite the potential advantage ofgreater anchorage of the drain, thereby reducing drain dis-placement and the reduced risk of bile leak.8 In the lattercomplication, infected bile is less likely to irritate the peri-toneum as the liver acts as a ‘shield’. Infected bile in theperitoneum is extremely painful and runs the risk of causingbile peritonitis which can be difficult to manage. There is,however, an increased risk of bleeding if the liver is to be crossed.

Once the route has been decided the patient is cleanedand draped. Local anaesthetic is applied to the skin, thegallbladder and to the liver capsule if the approach is to betrans-hepatic.

Once suitably anaesthetised, an 8Fr locking drain isinserted into the gallbladder using one of two techniques,the trocar or Seldinger approach. The first approach is asingle step process with the insertion of a standard threepart drain into the gallbladder (figure 3). The inner trocarand needle are then removed and the pigtail of the drainforms within the gallbladder (figure 4). This is a simple,quick technique that is favoured in our institution.

The Seldinger technique uses a fine needle to first punc-ture the gallbladder, a wire is then fed through the needleinto the gallbladder and the needle is then removed. Overthe wire a drain with a trocar is advanced until its tip isin the gallbladder. The wire and trocar are then removedallowing the pigtail to form in the gallbladder. Sometimesthe 8Fr drain will not pass over the wire and plastic dilatorsof increasing size need to be used in order for the drain toadvance into the gallbladder. This is a more cumbersomeprocedure with multiple steps but has the advantage of asmaller sized initial puncture which may reduce the risk ofbleeding. The drain is then sutured into the skin and a suit-able dressing applied. This is left on free drainage and asample taken for microbiology, culture and sensitivity. Ininfected systems it is almost always frank pus that is aspi-rated (figure 5). The patient is monitored in the departmentfor approximately 30 minutes before being returned to theward.

The external drain requires little in the way of manage-ment. The bag needs emptying as and when required andcare needs to be taken by both patient and staff to not dis-lodge the drain. As the drain is a potential source of bacte-rial entry the area around the insertion site needs to bekept clean. This can be difficult to manage, especially infrail patients, although most patients will have the drain inplace for a short time period only. Flushing daily with 10mlof sterile saline may help reduce drain blockage.

Technical success defined as satisfactory placement of adrain in the gallbladder is close to 90% with a clinical suc-cess rate defined by a reduction in inflammatory markers

and resolution of symptoms being as high as 86%.9,10

Complication rates are low at approximately 10%. Drainmigration is the commonest problem (8.6%) followed by bileleaks and bleeding. Bowel perforation and pneumothoraxare rare.11,12

Internal drainageIn those select patients who need permanent gallbladderdrainage, the problems with external drainage relating todisplacement, blockage and infection can be difficult to over-come. Routine replacement of the drain at three-monthintervals helps but has a cost implication and is inconve-nient for the patient. These patients can benefit from defin-itive internal drainage of the gallbladder. Endoscopicallyplaced stents between the gallbladder and bowel have beendescribed, as have fluoroscopic cystic duct stents. This lattertechnique performed by interventional radiologists places astent between the gallbladder and duodenum via the cysticduct.

Using fluoroscopy a wire is placed via the existing chole-cystostomy into the gallbladder. Using a catheter, ahydrophilic wire is then manipulated through the cystic andcommon bile duct into the duodenum. A double pigtail stentis then placed such that one end is in the duodenum andthe other is in the gallbladder (figure 6).

A covering cholecystostomy is left in place for a few days.Once internal drainage has been confirmed the externaldrain can be removed. Technical success rates as high as91% have been demonstrated. Difficulties include passing awire through the cystic duct which can be extremely tortu-ous in some patients, and crossing strictures of the commonbile duct.13

SummaryLaparoscopic cholecystectomy remains the ideal treatmentoption in AC for those patients fit enough for surgery.Minimally invasive percutaneous cholecystostomy is a validalternative as a bridge to surgery or as a definitive treat-ment plan in those with multiple co-morbidities. The lattergroup of patients may benefit from internalisation of thedrain with a cystic duct stent procedure.

References1, Elwood D R. Cholecystitis. Surg Clin North Am 2008;88:1241-52, viii.2, Wiseman J T, Sharuk M N, Singla A et al. Surgical management of acute

cholecystitis at a tertiary care centre in the modern era. Arch Surg 2010;145:439-44.

3, Morse B C, Smith J B, Lawdahl R B, Roettger R H. Management of acutecholecystitis in critically ill patients: Contemporary role for cholecystostomyand subsequent cholecystectomy. Am Surg 2010;76:708-12.

4, Ha J P, Tsui K K, Tang C N et al. Cholecystectomy or not after percuta-neous cholecystostomy for acute calculous cholecystitis in high-risk patients.Hepatogastroenterology 2008;55(86-87):1497-502.

5, Trowbridge R L, Rutkowski N K, Shojania K G. Does this patient haveacute cholecystitis? JAMA 2003;289:80-86.

6, Kendall J L, Shimp R J. Performance and interpretation of focused rightupper quadrant ultrasound by emergency physicians. J Emerg Med 2001;21:7-13.

7, Takada T et al. TG13: Updated Tokyo Guidelines for the management ofacute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sc 2013;20(1):1-7.

8, Little M W, Briggs J H, Tapping C R et al. Percutaneous cholecystostomy:The radiologist’s role in treating acute cholecystitis. Clin Radiol 2013;68:654-60.

9, Saad W E, Wallace M J, Wojak, J C et al. Quality improvement guidelinesfor percutaneous trans-hepatic cholangiography, biliary drainage and per-cutaneous cholecystostomy. J Vasc Interv Radiol 2010;21:789-95.

10, Winbladh A, Gullstrand P, Svanvik J et al. Systematic review of chole-cystostomy as a treatment option in acute cholecystitis. HPB (Oxford) 2009;11:183-93.

11, Pandanaboyana S, Mittapalli D, Marioud A et al. Clinical outcomes of apercutaneous cholecystostomy for acute cholecystitis: A multicentre analysis.HPB (Oxford) 2013;15:511-16.

12, Dewhurst C, Kane R A, Mhuircheartaigh J N et al. Complication rate ofultrasound-guided percutaneous cholecystostomy in patients with coagu-lopathy. AJR Am J Roentgenol 2012;199:753-60.

13, Hersey N, Goode S D, Peck R J, Lee F. Stenting of the cystic duct in benigndisease: A definitive treatment for the elderly and unwell. CardiovascIntervent Radiol 2015;38:964-70.

Figure 1Ultrasound image showing a thick walled gallblad-der (large arrow) with surrounding fluid (smallarrows). A positive sonographic Murphy’s sign wasdemonstrated.

Figure 3Ultrasound image showing the insertion of a three-part drain (arrow) using the trocar method.

Figure 4Removal of the inner trocar and needle allows thepigtail (arrows) of the drain to form within the gall-bladder.

Figure 2Corresponding unenhanced CT image. Thick walledgallbladder (large arrow) and surrounding fluid(small arrow) again demonstrated. The CT showed aperforated gallbladder – not seen on this image.

Figure 5Typical appearance of frank pus aspirated from aninfected gallbladder.

Figure 6Double pigtail stent deployed with one end in theduodenum (small arrow) and the other in the gall-bladder (large arrow).