Percutaneous cholecystostomy

Percutaneous transhepatic cholecystostomy (PTC) is a minimally invasive procedure used to drain the gallbladder in cases of acute cholecystitis or other conditions where the gallbladder cannot be drained via the usual routes. 

Indications for PTC

1. Acute Cholecystitis: In cases where the gallbladder is acutely inflamed and cannot be safely drained via percutaneous or endoscopic routes.
2. High Surgical Risk: Patients who are not suitable candidates for surgery due to comorbidities or high surgical risk.
3. Failed Conservative Management: When conservative management (such as antibiotics, analgesics) for acute cholecystitis is ineffective or contraindicated.
4. Bridge to Definitive Treatment: PTC may serve as a temporary measure to stabilize the patient before definitive treatment (such as cholecystectomy or endoscopic gallbladder drainage) can be performed.

Pre-procedure Preparation

1. Patient Assessment:
   • Comprehensive evaluation of the patient’s medical history, symptoms, laboratory tests (including liver function tests and inflammatory markers), imaging studies (such as ultrasound, CT scan), and coagulation profile.
   • Assessment of the severity of cholecystitis, presence of gallbladder stones or sludge, and risk of complications.
2. Informed Consent:
   • Explanation of the PTC procedure, its purpose, potential risks (such as bleeding, infection, bile leakage, injury to surrounding structures), benefits, and alternatives. Informed consent is obtained.

Procedure Steps

1. Patient Positioning:
   • The patient is typically positioned lying down on the procedure table, with the right upper quadrant of the abdomen exposed.
2. Local Anesthesia:
   • Local anesthesia is administered at the puncture site, usually in the right upper quadrant of the abdomen under ultrasound guidance.
3. Percutaneous Access:
   • A needle is inserted percutaneously through the skin and into the liver parenchyma under real-time ultrasound or fluoroscopic guidance.
   • Once the needle is positioned within the intrahepatic bile ducts, contrast material may be injected to confirm the appropriate location.
4. Cholecystostomy Tube Placement:
   • A guide wire is then advanced through the needle into the gallbladder.
   • Over the guide wire, a drainage catheter or cholecystostomy tube is inserted and positioned within the gallbladder lumen, allowing bile drainage.
5. Securing the Tube:
   • The cholecystostomy tube is secured in place with sutures or adhesive dressings to prevent dislodgement.
6. Post-procedure Imaging:
   • Post-procedure imaging (such as ultrasound or fluoroscopy) may be performed to confirm the placement of the cholecystostomy tube and assess for any immediate complications.

Benefits and Clinical Outcomes

• Relief of Symptoms: PTC effectively drains the gallbladder, reducing inflammation and alleviating symptoms such as abdominal pain, fever, and nausea associated with acute cholecystitis.
• Facilitates Definitive Treatment: PTC can serve as a bridge to definitive treatment, allowing time for patients to stabilize before undergoing cholecystectomy or other interventions.
• Reduces Surgical Risk: In high-risk surgical patients, PTC offers a minimally invasive alternative to surgical drainage of the gallbladder.
• Improves Patient Comfort: By draining bile and reducing gallbladder distension, PTC improves patient comfort and quality of life during the acute phase of cholecystitis.

Risks and Considerations

• Bleeding: Risk of bleeding at the puncture site or within the liver parenchyma during the procedure.
• Infection: Potential for catheter-related infections, although rare with proper aseptic techniques.
• Bile Leakage: Risk of bile leakage around the cholecystostomy tube insertion site, requiring close monitoring and management.
• Tube Dislodgement: Possibility of cholecystostomy tube dislodgement, necessitating repositioning or replacement.

Post-procedure Care

1. Monitoring:
   • Close monitoring of the patient’s vital signs, abdominal symptoms, and drainage output from the cholecystostomy tube.
   • Observation for signs of infection, bile leakage, or other complications.
2. Tube Care:
   • Regular care and flushing of the cholecystostomy tube as per institutional protocols to maintain patency and prevent occlusion.
   • Monitoring and recording of drainage output and characteristics (color, consistency) for assessment of bile flow and resolution of cholecystitis.
3. Antibiotics:
   • Prophylactic or therapeutic antibiotics may be prescribed based on the patient’s clinical condition, risk factors, and institutional guidelines.
4. Follow-up Imaging:
   • Follow-up imaging studies (such as ultrasound or CT scan) may be scheduled to assess resolution of cholecystitis, gallbladder size, and the need for further interventions.

Conclusion

Percutaneous transhepatic cholecystostomy (PTC) is a valuable procedure for draining the gallbladder in patients with acute cholecystitis who are not suitable candidates for surgery or endoscopic interventions. Close collaboration between interventional radiologists, gastroenterologists, and surgeons is essential for the successful planning, execution, and post-procedure care of PTC procedures. Regular monitoring, tube care, and follow-up imaging are crucial for optimizing outcomes and preventing complications in patients undergoing PTC