Ultrasound-guided percutaneous cholecystostomy in acute cholecystitis: case vignette and review of the technique

Abstract

Acute cholecystitis is a frequent condition. Although cholecystectomy is the indicated treatment of this entity, it cannot be performed in some high-risk surgery patients, such as critically ill or those with multiple comorbidities. In these non-uncommon scenarios, percutaneous cholecystostomy is the recommended alternative treatment, which allows immediate decompression and drainage of the acutely inflamed gallbladder and thus reducing the patient's symptoms and the systemic inflammatory response. Ultrasound is the imaging method of choice to guide the percutaneous cholecystostomy procedure due to its real-time guidance, lack of ionizing radiation and portability, avoiding the need to transfer unhealthy patients to the radiology department. We will review the ultrasound-guided percutaneous cholecystostomy procedure, of special interest for radiologists, surgeons, and also intensive care and emergency physicians.Keywords Acute cholecystitis Á Interventional radiology Á Ultrasonography Á Cholecystostomy Sommario La colecistiti acuta é una malattia frequente. Benché la colecistectomia laparotomica sia una procedura validata essa non è idonea nella popolazione ad alto rischio, quali i pazienti critici o quelli con elevate comorbiditá. In tali categorie il trattamento percutaneo é la procedura suggerita consentendo di decomprimere la colecisti e ridurre i sintomi sirs correlati. La metodica eco assistita real time e la procedura di scelta in considerazione della assenza di radiazioni e la facilitádi esecuzione in ambiti extra radiologici. Descriveremo di seguito la tecnica di colecistostomia eco guidata di interesse radiologico, chirurgico e rianimatorio.

Bedside Percutaneous Cholecystostomy

“…Using a convex probe at frequency range 2.5-6 MHz, the gallbladder is evaluated for the best approach. Conirm liver anatomy is as expected [1,2,11].…”

“…When using an intercostal approach, care must be taken to avoid puncturing the diaphragm, pleura or the intercostal neurovascular bundle as it passes inferior to the rib. The transhepatic approach decreases the risk of bile leaks and colon injury, which are more common in the transperitoneal approach [1,2,12,19]. Higher rates of bleeding are associated with the transhepatic approach [13].…”

“…The gold standard treatment for acute cholecystitis is surgical cholecystectomy [1][2][3]. In modern practice, this is most commonly performed via a laparoscopic approach [3].…”

“…When combined with antibiotics, this is an efective way to give the body time to lessen the inlammatory response in preparation for surgery. In patients with acalculous cholecystitis, PC can obviate the need for surgery [1,2]. Furthermore, it makes possible the ability to perform diagnostic cholangiography and access for intervention to eliminate common bile duct stones [4].…”

“…Options for image guidance include ultrasound, computed tomography, and luoroscopy. When performed at the bedside, this procedure is done with ultrasound guidance and has the advantage of avoiding the need to transfer patients to the operating room or Interventional Radiology suite [1,2,6]. …”