Cholecystostomy and transcholecystic biliary access.

Percutaneous cholecystostomy represents a minimally invasive procedure for providing gallbladder decompression, often in critically ill patient populations. Indications for this procedure include calculous and acalculous cholecystitis, gallbladder perforation, malignant obstruction, percutaneous biliary stone removal, biliary duct drainage, and diagnostic imaging of the gallbladder and biliary ductal system. In addition, gallbladder access provided by percutaneous cholecystostomy may serve to carry additional procedures, such as cholangiograms, gallstone dissolution, and lithotripsy. Review of prior imaging studies including ultrasound, CT, and hepatobiliary scans are essential to planning the procedure, by helping to determine the access route: transhepatic versus transperitoneal. The transhepatic route is preferred in cases of large ascities, bowel interposition, and offers the advantage of greater catheter stability. On the other hand, the transperitoneal route is preferred in the setting of coagulopathy and liver disease. Initial access is gained via insertion of an 18- to 22-gauge needle, followed by use of the Seldinger technique or trocar system to catheterize the gallbladder. Overall technical success rate for percutaneous cholecystostomy is greater than 95%. Clinical improvement is achieved in 56 to 93% of patients. Complications occur in 3 to 13% of cases and are mainly acute and minor. Major complications such as bile peritonitis, significant hemorrhage, and hemo/pneumothorax affect less than 5% of patients. However, sepsis and reported 30-day mortality rates of up to 25% are usually related to underlying morbidities in critically ill patients. Catheters may be removed once the fistula track has matured.