Image-Guided Intervention

Image-guided interventional techniques have been developed to provide minimally invasive treatment of gallbladder disease (see Chapters 28 and 31). Percutaneous, image-guided cholecystostomy is now an accepted method to decompress the acutely inflamed gallbladder if surgery is not indicated. Various methods aiming at elective, nonsurgical removal of gallbladder stones were introduced in the early 1990s, including extracorporeal shock-wave lithotripsy (ESWL), contact dissolution of gallstones with methyl tert-butyl ether (MTBE), and percutaneous mechanical cholecystolithotomy. As a result of the successful introduction of laparoscopic cholecystectomy (see Chapter 34), surgical treatment of cholecystolithiasis has become less invasive, and definitive treatment of cholecystolithiasis may be accomplished with much shorter hospitalization. Because none of the existing nonsurgical techniques of gallstone removal can prevent recurrent gallstone formation, the indication to perform percutaneous gallstone removal without surgery is now very limited. This chapter gives an overview of image-guided treatment methods for gallbladder disease.

Percutaneous Cholecystostomy for Acute Cholecystitis

Surgical cholecystostomy (see Chapters 28 and 31) has long been used to provide external decompression of the acutely inflamed gallbladder in patients who are at high risk for operation or general anesthesia, such as those with sepsis, diabetes, or severe cardiac, pulmonary, hepatic, or renal failure. Percutaneous cholecystostomy was initially developed to provide a minimally invasive method of gallbladder decompression in elderly and very ill patients with acute acalculous or calculous cholecystitis or with gallbladder hydrops secondary to malignant disease (Elyaderani & Gabriele, 1979; Pearse et al, 1984). Percutaneous cholecystostomy also has been used to treat complications of cholecystitis (e.g., gallbladder perforation, empyema, or pericholecystic abscesses) or as an alternative to percutaneous transhepatic drainage of the bile ducts in obstructive jaundice. More recently, percutaneous cholecystostomy has been used to provide access to the gallbladder for elective gallstone treatment with stone dissolution techniques, percutaneous cholecystolithotomy, or other techniques.

The percutaneous access route to the gallbladder usually is determined with ultrasound (US) and is based on the individual anatomic situation. Computed tomography (CT) can be used if US does not provide sufficient information. Most authors favor the transhepatic approach to the gallbladder, because a puncture through the attached portion of the gallbladder should reduce the risk of bile leakage into the peritoneal cavity (Fig. 32.1). The area of attachment cannot be anticipated reliably with imaging techniques, and the direct, transperitoneal route also has been used successfully (Vogelzang & Nemcek, 1988). The acutely inflamed gallbladder is usually distended and immediately adjacent to the anterior abdominal wall, and the direct approach through the gallbladder fundus avoids the trauma to the liver that may be associated with percutaneous gallstone removal at a later date. The use of a removable percutaneous anchor was proposed to prevent the gallbladder wall from moving away from the trocar or from the catheter during exchange over a guidewire (Cope et al, 1990).

FIGURE 32.1 Percutaneous cholecystostomy for acute acalculous cholecystitis in a 74-year-old patient with recent myocardial infarction. A, Contrast-enhanced computed tomography (CT) for planning shows inflammation of the gallbladder wall and hyperdense content. B, The puncture of the gallbladder across liver parenchyma is performed with a 20-gauge needle under CT fluoroscopy. C, A 6-Fr pigtail drain is placed in the gallbladder using a Seldinger technique. D, Ten days later, the drain has been removed, and contrast-enhanced CT shows the gallbladder with decreased inflammation.

The initial gallbladder puncture is performed under local anesthesia, and prophylactic administration of atropine has been recommended to prevent vasovagal reactions (vanSonnenberg et al, 1984). With portable US equipment, the percutaneous cholecystostomy procedure can be performed at the patient’s bedside (e.g., in the intensive care unit). If there is doubt regarding a safe access route, however, it may be preferable to combine US or CT with fluoroscopy (Fig. 32.2). Several suitable needle/catheter or needle/guidewire systems are available, and the optimal method of catheter introduction is a matter of personal preference. Repeat punctures with introducer needles should be avoided, because leakage of gallbladder content through the puncture channel may lead to internal decompression of the gallbladder into the peritoneal cavity and prevent further attempts to enter the gallbladder lumen. A catheter size of 6.5 to 7 Fr is usually sufficient to provide effective external gallbladder drainage, but 8 Fr or more may be necessary to drain gallbladder empyema or pericholecystic abscesses (Fig. 32.3; vanSonnenberg et al, 1991). If percutaneous cholecystostomy is done for acute cholecystitis, catheter manipulations should be kept to a minimum to avoid inadvertent perforation of the frail inflamed gallbladder wall or leakage of gallbladder contents alongside the catheter. To prevent inadvertent dislodgment of the catheter on the ward, it is preferable to use a self-retaining catheter. Diagnostic cholangiography through the cholecystostomy catheter may be obtained after a few days to assess the presence of gallstones and patency of the cystic duct. It is advisable to leave the cholecystostomy catheter in place for 7 to 10 days to let a tract develop and to avoid bile leakage into the peritoneal cavity.

FIGURE 32.2 Percutaneous transhepatic cholecystostomy for acute acalculous hemorrhagic cholecystitis. After an initial gallbladder puncture under ultrasound guidance with a 22-gauge needle, the procedure was continued under fluoroscopic control. A, Direct cholecystography showed a large filling defect in the infundibulum of the gallbladder. B, The 22-gauge access was converted to a larger caliber, and a guidewire was introduced into the gallbladder. A 6.5-Fr self-retaining pigtail catheter was placed in the gallbladder lumen. There was no opacification of the cystic duct at the time of the initial procedure. C, Repeat cholangiography was done 1 week after emergency cholecystostomy. The cystic duct was patent, and there was unimpeded flow of contrast material into the duodenum. Most of the debris within the gallbladder had disappeared. The cholecystostomy catheter was removed 1 week after cholecystostomy; elective cholecystectomy was not required.

FIGURE 32.3 Gallbladder empyema with perforation and pericholecystic abscess formation. A, Computed tomography shows a distended gallbladder (gb) with a perforated wall (arrowhead) and pericholecystic abscesses (a). B, Using a subhepatic access under ultrasound guidance, a catheter was placed through the gallbladder fundus within the gallbladder lumen and drained pus. Injection of contrast material showed the gallbladder lumen and at least two sites of perforation communicating with pericholecystic abscesses (arrowheads).

Although transient right upper quadrant pain is a relatively common side effect of percutaneous cholecystostomy, serious procedure-related complications are uncommon. In a review of 252 percutaneous cholecystostomies reported in the English language literature, there were 4 cases of bile peritonitis and 1 death (0.3%); other procedure-related complications included vasovagal reaction or hypotension, self-limited hemobilia, and acute cholecystitis secondary to an impacted stone in the cystic duct (Teplick, 1989). In a series of 127 patients undergoing gallbladder puncture and cholecystostomy, the reported rate of minor and major complications was 3.9% and 8.7%, respectively. The 30-day mortality rate of that series was 3.1%, but all deaths were due to underlying diseases (vanSonnenberg et al, 1992).

In view of the severely compromised health of most patients undergoing the procedure, percutaneous cholecystostomy is relatively safe. The efficacy of percutaneous cholecystostomy is difficult to determine, because the diagnosis of acute cholecystitis is often unreliable in patients with multiple concomitant medical and surgical problems (McGahan & Lindfors, 1988, 1989). If the indication for percutaneous cholecystostomy is restricted to patients with clinical or imaging findings of acute cholecystitis, a response rate of 90% can be expected (van Overhagen et al, 1996). If patients with unexplained abdominal sepsis are included, the response rate is lower (Boland et al, 1994; Lee et al, 1991; McGahan & Lindfors, 1989). In patients with acute acalculous cholecystitis, interval cholecystectomy may be unnecessary, and percutaneous cholecystostomy may be a definitive therapy (Vauthey et al, 1992). A randomized, controlled trial showed that percutaneous cholecystostomy and drainage is significantly more effective than simple gallbadder aspiration (Ito et al, 2004). Results of retrospective clinical studies on percutaneous cholecystostomy are summarized in Table 32.1. Current experience indicates that percutaneous cholecystostomy is an effective temporizing measure in elderly or critically ill patients with acute cholecystitis and a safe alternative to emergency surgery (Chok et al, 2010). Recently, this has been recognized by a surgical consensus conference (Miura et al, 2007). In clinical situations that warrant, interval cholecystectomy can be performed on an elective basis.

Nonsurgical Techniques to Remove Gallbladder Stones

Percutaneous Gallstone Removal via Cholecystostomy

Percutaneous Contact Dissolution of Gallbladder Stones with Methyl Tert-Butyl Ether

MTBE is the most potent cholesterol solvent available. Because of its boiling point of 55.2° C, it remains liquid at body temperature and is easier to handle than diethyl ether. Direct instillation of MTBE through a small percutaneous cholecystostomy catheter has been used successfully to dissolve cholesterol stones of the gallbladder within hours (Allen, 1985). Most treatments with MTBE have been done on an elective basis in patients who had an increased risk of surgery or anesthesia because of coexisting medical conditions or who refused to undergo surgery for other reasons (Hellstern et al, 1990; Thistle et al, 1989). The selection criteria for MTBE therapy includes symptomatic uncomplicated gallstone disease, uncalcified gallstones on CT, and normal hepatic laboratory test results.

The use of MTBE requires several precautions. Because of its unpleasant odor, inflammability, and anesthetic effect, MTBE must be used in a well-ventilated room. Catheters, syringes, and stopcocks must be made of special materials, such as Teflon, polyethylene, glass, and metal. After percutaneous cholecystostomy, a 5-Fr pigtail catheter is positioned within the gallbladder under fluoroscopic control so as to provide close contact with the gallstones to be dissolved. The gallbladder overflow volume is assessed by contrast injection into the gallbladder. A similar volume of MTBE is instilled and aspirated in continuous cycles (Fig. 32.4). Depending on the stone volume, complete dissolution is usually accomplished during a hospitalization of 2 to 3 days with several hours of treatment each day.

FIGURE 32.4 Percutaneous dissolution of cholesterol gallstones with methyl tert-butyl ether (MTBE). A, Direct cholangiography obtained through a cholecystostomy catheter showed multiple small calculi in the gallbladder lumen. B, After a few hours of MTBE dissolution treatment, the stone volume had diminished considerably.

Minor side effects include nausea, vomiting, or a burning sensation in the right upper abdomen, which may be due to the drug itself, to minor leakage of bile alongside the catheter, or to catheter manipulations within the gallbladder. Serious complications, such as major bile leakage, hemobilia, or stone impaction in the cystic duct or common bile duct, are uncommon. The success rate of MTBE dissolution treatment has been reported to be 96%, although residual debris was still visible on US in many patients at the time of discharge (Hellstern et al, 1990; Thistle, 1991; Thistle et al, 1989). In the era of laparoscopic cholecystectomy, indications for MTBE dissolution treatment of gallbladder calculi are rare (see Chapter 34).

Percutaneous Cholecystolithotomy

The term percutaneous cholecystolithotomy is used to describe a variety of techniques to remove gallbladder stones percutaneously. In contrast to MTBE dissolution treatment, percutaneous cholecystolithotomy can be done regardless of the size, number, and composition of the calculi. A small, shrunken, thick-walled gallbladder generally is considered a contraindication to all forms of percutaneous cholecystolithotomy. The common steps of all techniques of percutaneous cholecystolithotomy are 1) percutaneous access to the gallbladder by means of percutaneous cholecystostomy; 2) immediate or sequential dilation of the cholecystostomy tract to a relatively large size, ranging from 10 to 30 Fr; 3) introduction of instruments for gallstone fragmentation and removal; and 4) external drainage of the gallbladder after the procedure (Akiyama et al, 1985; Kerlan et al, 1985).

Regardless of the technique used for tract dilation, the procedure is painful unless performed under intravenous sedation or general anesthesia. The most important risks are hemorrhage if a transhepatic access is used and bile leakage and loss of access if a subhepatic transperitoneal route is chosen. Smaller calculi can be removed with wire baskets (Cope et al, 1990). Fragmentation of larger calculi may be done with electrohydraulic, ultrasonic, or laser-mediated intracorporeal lithotripsy (Bogan et al, 1989; Burhenne, 1975; Gillams et al, 1992; Picus et al, 1989). These techniques require direct contact between the lithotripsy probes and the calculi under endoscopic vision. The rotary gallstone lithotrite was specially designed for percutaneous gallstone lithotripsy and enables pulverization of gallbladder calculi in a manner similar to a household blender: the device consists of a six-pronged basket surrounding a 3-mm impeller, which rotates in a 7-Fr catheter at 30,000 rpm, pulling the stones into the basket and crushing the stones into fragments smaller than 2 mm within minutes (Miller et al, 1991a, 1991b, 1991c). This technique can be performed under fluoroscopic vision and requires a percutaneous tract no larger than 10 Fr. Because the device must be able to open freely within the gallbladder, the stone volume should not exceed 75% of the volume of the gallbladder (Fig. 32.5).

FIGURE 32.5 Percutaneous cholecystolithotomy with the rotational lithotrite. A, Access to the gallbladder was established by percutaneous transhepatic cholecystostomy using a right anterolateral entry into the gallbladder. The catheter entered the gallbladder wall in its distal half, and there were multiple filling defects as a result of calculi. B, After dilation of the percutaneous tract, the rotational lithotrite with its sheath has been introduced into the gallbladder lumen. The gallbladder was distended with dilute contrast material, and the calculi were well visualized. The struts around the propeller protected the gallbladder wall, whereas the calculi were attracted into the propeller by a vortex created within the gallbladder fluid.

The technical success rate of percutaneous cholecystolithotomy is 88% (Gillams et al, 1992). Procedure-related complications occur in 15% and include subhepatic bile collections, cholangitis, gallbladder perforation with pericholecystitis, and wound infections. Although in the early 1990s elective percutaneous cholecystolithotomy was proposed to avoid cholecystectomy in patients with symptomatic but uncomplicated cholecystolithiasis, this indication seems to be obsolete in the era of laparoscopic cholecystectomy. Now most procedures are done on an elective basis.

Combined Surgical and Radiologic Intervention: Minicholecystostomy

The minicholecystostomy procedure was described by Burhenne and Stoller (1985) and included provision of emergency decompression of the gallbladder and the possibility of percutaneous stone removal 7 to 10 days later without the need for tract dilation. After localization of the gallbladder by US, a small abdominal incision is made over the gallbladder fundus under local anesthesia and intravenous analgesia. A 24-Fr Foley catheter is placed into the gallbladder, and the fundus of the gallbladder is sutured to the combined peritoneum and posterior layer of the rectus sheath, creating a short, wide tract. After 1 week of external gallbladder drainage, the gallstones can be removed under fluoroscopic control, usually without analgesia. Large stones can be fragmented with stone-crushing forceps and removed mechanically with a variety of instruments (Fig. 32.6).

FIGURE 32.6 Mechanical cholecystolithotripsy through a subhepatic surgical minicholecystostomy. A, Because the gallbladder fundus had been sutured to the anterior abdominal wall at the time of emergency cholecystostomy, percutaneous tract formation was not necessary, and percutaneous gallstone removal was feasible 1 week later through a short, straight, 24-Fr percutaneous tract. The Storz stone-crushing forceps was introduced into the gallbladder, and a large calculus was fragmented. B, The fragments subsequently were extracted with the Mazzariello-Caprini forceps.

The minicholecystostomy approach avoids the risks of hepatic hemorrhage, bile leakage, and vasovagal reactions associated with dilation of a percutaneous cholecystostomy tract, and it facilitates repeated subhepatic access to the gallbladder. The success rate of stone removal was 97% for gallbladder stones, 86% for cystic duct stones, and 63% for common bile duct stones; no serious complications and no deaths resulted (Burhenne & Stoller, 1985; Gibney et al, 1987). Given the safety and efficacy of laparoscopic cholecystectomy and percutaneous cholecystostomy, this technique is rarely indicated.

Summary

Percutaneous image-guided cholecystostomy offers a minimally invasive treatment of acute cholecystitis in high-risk patients. In acalculous disease, percutaneous cholecystostomy alone may be curative, unless the gallbladder wall already has become necrotic in the course of gangrenous cholecystitis. In calculous disease, interval cholecystectomy usually is required, although percutaneous gallstone removal through the cholecystostomy tract may be preferable in some cases. The indication for elective percutaneous gallstone removal by means of MTBE or percutaneous cholecystolithotomy has virtually disappeared, because the hospitalization required for these procedures is similar to that of laparoscopic cholecystectomy, and a definitive cure cannot be provided. ESWL is a noninvasive outpatient procedure and may be considered as a useful treatment option in the small group of patients who fulfill the selection criteria. Because of the relatively high recurrence rates observed in recent studies, however, laparoscopic cholecystectomy seems to be the more effective treatment.