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Gallbladder Intervention


Gallbladder intervention in the form of gallbladder decompression was first proposed as a definite technique in the second half of the last century. However, percutaneous gallbladder intervention did not gain widespread acceptance because of the fear of bile leakage and life-threatening vagal reactions. It was not until the 1980s that percutaneous drainage of the gallbladder and other percutaneous therapies for gallstones became popular.

Percutaneous gallbladder intervention can be divided into diagnostic and therapeutic techniques. Diagnostic techniques include gallbladder aspiration, biopsy, and diagnostic cholecystocholangiography. Therapeutic techniques include percutaneous cholecystostomy, biliary drainage and stent placement via the gallbladder, MTBE (methyl-tert-butyl ether) dissolution therapy, percutaneous cholecystolithotomy, and gallbladder ablation. Apart from percutaneous cholecystostomy, many of these techniques are infrequently performed. The advent of laparoscopic cholecystectomy, to a large extent, has meant the demise of percutaneous techniques to treat gallstones such as percutaneous cholecystolithotomy and MTBE dissolution therapy.

Diagnostic Gallbladder Intervention

Gallbladder Aspiration

Aspiration of bile for Gram stain gained some popularity in the 1980s in intensive care units (ICUs) or in critically ill patients with suspected acute calculous or acalculous cholecystitis. The lack of an accurate noninvasive test to diagnose cholecystitis in these patients led to the practice of gallbladder aspiration for Gram stain and culture of bile. Using ultrasound guidance, a 20- to 22-gauge needle was placed in the gallbladder and bile aspirated for microbiologic analysis. However, the accuracy of gallbladder aspiration in this clinical situation is approximately 50%, which is equivalent to tossing a coin. Additionally, one has to wait several days for culture results. A major reason for the lack of sensitivity is that patients are often on broad-spectrum antibiotics before gallbladder aspiration so that Gram stains may be negative even in the presence of acute cholecystitis. This procedure has largely been abandoned because of the low sensitivity.

Diagnostic Cholecystocholangiography

In limited clinical situations, diagnostic cholecystocholangiography may be performed instead of percutaneous transhepatic cholangiography. In patients with minimally sized intrahepatic bile ducts, who only require a diagnostic study, a gallbladder puncture can be used. In the author’s unit we usually perform transhepatic cholangiography first, and only if this fails do we resort to a gallbladder puncture. A 22-gauge needle is placed in the gallbladder under ultrasound guidance and contrast material injected under fluoroscopy. If the cystic duct is open, contrast material flows into the common bile duct and common hepatic duct. It may be necessary to place the patient in Trendelenburg position for contrast medium to fill the intrahepatic ducts fully. If the patient requires therapeutic procedures with biliary drainage or stent placement, it is best to use a transhepatic route, because it may be difficult to manipulate stents and catheters through the cystic duct into the common bile duct ( Box 21-1 ).

Box 21-1
Diagnostic Cholecystocholangiography

  • Use only if intrahepatic ducts minimally dilated and if transhepatic approach fails

  • Biliary obstruction must be at a level below junction of cystic duct and common hepatic duct

  • Ultrasound guidance and a 22-gauge needle are used

  • Trendelenburg positioning may be necessary to fill intrahepatic ducts

Gallbladder Biopsy

The gallbladder wall can be biopsied successfully using small (20- or 22-gauge) needles, if there is a gallbladder mass ( Fig. 21-1 ). Gallbladder masses are usually due to either primary gallbladder adenocarcinoma or metastatic disease. The procedure is usually performed under ultrasound guidance and has a success rate of more than 90% in obtaining a diagnosis. It is best to use small needles to prevent bile leakage. However, if the mass is large and the gallbladder lumen is totally replaced, then cutting needles (e.g., Tru-Cut) can be used.

Figure 21-1, Gallbladder biopsy. Transverse image from an ultrasound of the right upper quadrant showing the gallbladder (large arrows) containing predominantly solid material. The patient was suspected to have a gallbladder cancer. A fine-needle biopsy was performed under ultrasound guidance and the needle (small arrows) can be seen within the mass. Gallbladder cancer was confirmed upon pathologic examination of the biopsy specimen.

Therapeutic Gallbladder Intervention: Percutaneous Cholecystostomy

Percutaneous cholecystostomy is a valuable technique for the management of patients with either calculous or acalculous cholecystitis who are critically ill and unfit for surgery. In these patients, percutaneous cholecystostomy is performed as a temporizing measure, with definitive surgery carried out at a later date when the patient has recovered from the acute illness. In acalculous cholecystitis, percutaneous cholecystostomy may be curative in that once the inflammation resolves the patient may not need a cholecystectomy. Percutaneous cholecystostomy is also useful in the management of empyema and hydrops of the gallbladder.

Percutaneous cholecystostomy has also been used for drainage of the biliary tree in patients whose cystic duct is patent and the biliary obstruction lies below the insertion of the cystic duct into the common bile duct. Transhepatic biliary drainage is usually a better alternative for long-term drainage of the biliary tree, but in selected cases percutaneous cholecystostomy may be of benefit. Selected clinical situations include pancreatitis wherein short-term decompression of an obstructive biliary tree may be necessary, and biliary cholangitis and distal obstruction of the common bile duct for which endoscopic retrograde cholangiopancreatography (ERCP) has failed to provide drainage. For long-term palliation of patients with obstructive jaundice, the transhepatic route is preferred because stenting can be performed easily through the transhepatic tract. It can be difficult to manipulate a wire through the cystic duct and into the common bile duct using a gallbladder approach. Additionally, long-term catheter drainage of the biliary tree via the gallbladder in patients with distal malignant obstruction is not optimal because both pancreatic cancer and cholangiocarcinoma eventually grow to obstruct the origin of the cystic duct. For these reasons, percutaneous cholecystostomy for decompression of the biliary tree is only performed for temporary decompression and only in selected patients ( Fig. 21-2 ).

Figure 21-2, Percutaneous cholecystostomy for drainage of the biliary tree in a patient with severe cholangitis and hypotension. A percutaneous cholecystostomy catheter (arrow) was placed in the gallbladder using the Seldinger technique. A stricture can be seen in the lower bile duct, caused by a small pancreatic tumor. The catheter remained in situ until the patient went to surgery for a Whipple procedure.

Technique

There are a number of technique variations to consider before performing a percutaneous cholecystostomy. The access route used can be either transhepatic or transperitoneal, while the catheter can be placed using either a Seldinger or trocar technique. The access route and method of catheter insertion chosen is a matter of personal preference. The author’s unit has tended to place cholecystostomy catheters using ultrasound guidance and trocar technique in ICU patients, while patients who can travel to the department may have the procedure performed using a Seldinger or trocar technique.

Transperitoneal vs. Transhepatic Access

Use of a transhepatic or transperitoneal approach is largely a matter of personal preference. Many authors prefer the transperitoneal approach because it is more direct and avoids the necessity of going through the liver. Additionally, if percutaneous cholecystectolithotomy (PCCL) is being considered, a track can safely be dilated if a transperitoneal approach has been used. One of the main problems with the transperitoneal approach is that catheters and guidewires often buckle outside of the gallbladder, particularly when using the Seldinger technique. This is due to gallbladder mobility. The closer the entry site to the fundus of the gallbladder, the more mobile the gallbladder is and the more likely this is to happen ( Fig. 21-3 ). The Seldinger technique also increases the likelihood of this happening. Additionally, the transverse colon may occasionally overlie the fundus of the gallbladder and may result in perforation of the transverse colon if the transperitoneal approach is used ( Fig. 21-4 ).

Figure 21-3, Transhepatic versus transperitoneal insertion of gallbladder catheters. A, Schematic diagram showing the gallbladder (GB) with bare area (BA) shown near the neck of the gallbladder. The bare area represents the extraperitoneal surface of the gallbladder or the attachment of the gallbladder to the liver. A transhepatic insertion (large arrow) will be nearer the bare area and thus the gallbladder will be less mobile in this location than if a transperitoneal access route is chosen. B, A transperitoneal insertion is nearer the fundus of the gallbladder, which is also the most mobile portion of the gallbladder. The gallbladder wall may indent and move away from the needle or catheter using a transperitoneal approach. In addition, dilators or even the catheter may catch in the wall of the gallbladder and cause the guidewire to buckle outside the lumen of the gallbladder.

Figure 21-4, Clinical example showing a transperitoneal insertion of a percutaneous cholecystostomy catheter. The catheter can be seen (arrow) entering the gallbladder through the peritoneum. Note the position of the colon more anterior, indicating that an anterior approach was not possible in this patient.

The author prefers the transhepatic approach because entry of the catheter into the gallbladder is closer to the attachment of the gallbladder to the liver (the bare area) where the gallbladder is relatively fixed in position compared to the fundus. The bare area represents the attachment of the gallbladder to the liver and also represents the extraperitoneal surface of the gallbladder. The bare area is situated superolaterally in the gallbladder fossa and, in an ideal world, it would be best to place catheters through the bare area into the gallbladder. Thus, any bile leakage would be extraperitoneal and tamponaded by the liver. However, in practice it is very difficult to traverse the bare area because its precise location cannot be determined by any imaging method. In the author’s unit we therefore insert the catheter vertically into the gallbladder, making sure that the catheter passes through a portion of the liver en route to the gallbladder ( Fig. 21-5 ). One of the potential disadvantages of using the transhepatic approach is that if a PCCL is required at a later stage, a large track through the liver will have to be created. Some operators are reluctant to dilate a 1-cm tract through the liver into the gallbladder. We have done this on a considerable number of patients without mishap ( Boxes 21-2 and 21-3 ).

Figure 21-5, Example of a transhepatic catheter insertion into the gallbladder in a patient with acalculous cholecystitis. The catheter (arrow) is inserted through the liver into the gallbladder. Although the catheter almost certainly does not traverse the bare area, the gallbladder is less mobile with a transhepatic route.

Box 21-2
Advantages and Disadvantages of Transhepatic Approach for Percutaneous Cholecystostomy

  • Catheter entry site closer to the bare area of the gallbladder

  • Bile leaks potentially tamponaded by liver

  • Gallbladder less mobile closer to bare area

  • If large tracks required for percutaneous cholecystectolithotomy, risk of hemorrhage increased

Box 21-3
Advantages and Disadvantages of Transperitoneal Approach

  • Gallbladder more mobile near the fundus and may be more difficult to puncture

  • Transverse colon may overlie fundus of gallbladder

  • Seldinger technique prone to guidewire buckling when transperitoneal approach used

  • Large tracks can be easily dilated for percutaneous cholecystectolithotomy, if required

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