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Rescue in critical moments: When is cholecystostomy necessary?
Cholecystostomy is an important medical procedure designed to drain the gallbladder either percutaneously or endoscopically. This surgery has a long history and was first performed by American surgeon John Stough Bobbs in 1867. Cholecystostomy is still widely used in clinical practice today, especially in cases of acute cholecystitis or other gallbladder diseases. Cholecystostomy becomes a critical rescue measure when patients are unable to tolerate cholecystectomy due to poor health.
Indications
Cholecystostomy is mainly suitable for patients who are clinically unstable, cannot tolerate anesthesia, or have high surgical risk.
The following are some indications for cholecystostomy:
- Clinically unstable critically ill patients.
- Patients who cannot tolerate anesthesia.
- High-risk patients with severe systemic diseases (class III according to ASA physical status).
- Patients with poor response to medical management (no clinical improvement after at least 72 hours of medical treatment).
- Severe acute cholecystitis (Grade III acute cholecystitis) according to Tokyo guidelines.
Contraindications
Contraindications to cholecystostomy include coagulopathy, intervention of intestinal contents between the skin and gallbladder, biliary peritonitis, and ascites.
Percutaneous cholecystostomy
Method introduction
Percutaneous cholecystostomy is usually performed under sedation and guided by ultrasound or computed tomography. There are three main considerations for this surgical approach:
- Through the liver:This is the most common method, where a puncture is made on the liver and into the gallbladder. The advantages of this method include a reduced risk of bile leakage due to the close contact between the liver and gallbladder, and it is more suitable for patients with severe ascites.
- Peritoneal approach: This approach is used when a transhepatic approach is not possible due to anatomical challenges or liver disease. The main advantage of this is to reduce the risk of liver bleeding, but it increases the possibility of bile leakage.
- Subcostal vs. intercostal selection: It is generally believed that the intercostal approach is closely related to the neurovascular bundles in the lungs and under the ribs, and may cause higher pneumothorax, thoracic biliary fistulas, and nerve injury, so the subcostal approach is usually chosen.
Technical process
Before the operation begins, the doctor will comprehensively evaluate the patient's imaging data to ensure that the patient's physical condition is suitable for surgery. Before surgery, the surgical site will be cleaned with disinfectant and local anesthesia will be administered. A small incision will be made in the right upper abdomen to create a cholecystostomy.
"The Seldinger technique and the trocar technique are the two main methods of performing cholecystostomy."
The Seldinger technique uses a catheter and a progressively larger needle to create a cholecystostomy, which reduces the risk of puncture, while the trocar technique involves inserting an eight-inch drainage tube. Both methods have their pros and cons, but both are designed to drain the gallbladder safely and effectively.
Complications
Although cholecystostomy is relatively safe, approximately 10% of patients will develop complications. These complications can range from minor, such as duct dislocation, blockage, or bile leakage, to major complications, such as sepsis, major bleeding, pneumothorax, and intestinal damage.
Endoscopic cholecystostomy
In addition to percutaneous cholecystostomy, endoscopic cholecystostomy is also a feasible method. There are two main techniques: endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound-guided Gallbladder emptying (EUS-GBD). These techniques are suitable for patients who are not candidates for surgical cholecystectomy.
Endoscopic retrograde cholangiopancreatography
Endoscopic gallbladder emptying is performed through ERCP examination, and a plastic stent can be installed during the drainage process. Disadvantages of this approach are the potential for pancreatitis and lower success rates.
Endoscopic ultrasound-guided gallbladder emptying
EUS-GBD is cauterized and punctured into the gallbladder, and a metal stent is installed for internal drainage. This is a surgical option with a higher success rate, although one still needs to be aware of the potential risk of stent obstruction caused by food or stomach contents.
Conclusion
As a rescue method in critical moments, cholecystostomy provides a way out for many high-risk patients. As technology advances, so does the safety and effectiveness of this procedure. However, under what circumstances do we need to take such measures? It is still worthy of our careful consideration.
