Abstract
The incidence of gallstone-related complications is rising, thus leading to increases in waiting list times for elective laparoscopic cholecystectomy (LC). Percutaneous cholecystostomy (PC) provides immediate biliary drainage and may be used as an emergency option in a critically unwell patient as a bridge to surgery, or as the management option of a patient who is not fit for surgery. However, a significant number of these patients may be readmitted after PC with recurrent acute cholecystitis or pancreatitis, leading to significant morbidity and mortality. The aim of the present review was to analyze the available literature surrounding the use of the transcystic approach, including the extraction and balloon expulsion method, in the management of patients with gallbladder stones and/or common bile duct (CBD) stones. The full text of 18 articles were reviewed, of which four were included in this review. Results showed an overall success rate of CBD stone extraction in 118 of 139 patients (84.9%), gallbladder stone extraction in 97 of 114 (85.0%), and CBD stone expulsion in 27 of 29 (93.1%). Percutaneous CBD and gallbladder stone extraction may be a safe management option for elderly or co-morbid patients who are not appropriate for surgical intervention. However, the evidence base surrounding this is very limited; therefore, further research is required in order to evaluate this in more detail.
Introduction
The incidence of gallstone-related complications is rising (1), thus leading to increases in waiting list times for elective laparoscopic cholecystectomy (LC) (2). With the operational pressures that the National Health Service (NHS) is facing, made significantly worse by the 2020 COVID-19 pandemic (3), patients are often facing delays of over 12 months for the treatment of gallstone disease (4). The gold standard management of acute calculous cholecystitis (ACC) remains a LC with the multicentered “Chocolate” study (5), which demonstrated the benefits of cholecystectomy when compared to percutaneous cholecystostomy (PC) for those felt fit enough to undertake LC. However, there are a number of factors that limit its real-life application, including the logistics of performing surgery within the first 72 h or the patients’ clinical status, including those admitted to the intensive care unit (ICU) with sepsis who were excluded from this study. PC provides immediate biliary drainage and may be used as an emergency option in a critically unwell patient as a bridge to surgery, or as the management option of a patient who is not fit for surgery.
A limiting factor of PC is that gallbladder calculi are left in situ, thus increasing the risk of recurrent ACC. Moreover, the presence of concurrent common bile duct (CBD) stones in 10%–15% of patients (6) can significantly increase morbidity and mortality. The management options for associated CBD stones are endoscopic retrograde cholangiopancreatography (ERCP) or bile duct exploration at the time of LC (7), both of which are not without established complication and risk profiles. Percutaneous transcystic removal of CBD stones provides an alternative management option in severely unwell patients who are not candidates for surgical management. This allows for CBD or gallbladder stones to be removed using the same tract that was formed during a PC. There are two methods described in the literature for the removal of CBD stones: extraction or expulsion into the duodenum. Both procedures follow PC by cannulating the CBD via the gallbladder and cystic duct. The transcystic extraction technique utilizes an over-the-wire basket retrieval system to remove the stones via the PC access. This is contrasted with the expulsion method, which, after dilation of the ampulla of Vater, places a wire-mounted balloon behind the stones within the CBD progressively dilating to pass the stone through to the duodenum.
The aim of the present review was to analyze the available literature surrounding the use of the transcystic approach including extraction and balloon expulsion method in the management of patients with ACC and/or CBD stones.
Methods
Search strategy
A review of published research items was performed using both Medical Subject Headings (MeSH) terms and free-text terms. The databases PubMed, MEDLINE, EMBASE, Cochrane, CINAHL, and AMED were searched for relevant articles. A review of the reference lists of all relevant studies was performed to identify any missed articles by the search terms.
Study selection and assessment
Initial screening based on titles and abstracts was performed, and then full-text articles were reviewed to confirm eligibility. For a study to be included, a percutaneous transcystic approach must have been used in the treatment of acute calculous cholecystitis, cholangitis, or choledocholithiasis. Studies in which a transhepatic approach was used were excluded, even if the patient had had a prior PC. Major complications were defined as those that required procedural intervention.
Results
The full texts of 18 articles were reviewed, of which four (8–11) were included in this review (Fig. 1).
Flow chart search strategy.
Two of the included studies (8,9) performed CBD and gallbladder stone extraction or fragmentation via the cystic duct. This involved a standard ultrasound-guided cholecystostomy being performed using a Seldinger technique. Following an improvement in the clinical condition of the patient, usually over a period of 6–7 days, subsequent stone removal was then performed. Using the cholecystostomy drainage catheter, the cystic duct was catheterized and a guide wire inserted through the CBD and ampulla of Vater. This guide wire was then used to straighten the cystic duct before the CBD was then catheterized over the top of the previously placed guide wire. A stone basket set was then placed proximal to the CBD stone position and the stone was grasped and extracted. If large stones were present, these could be fragmented within the CBD before removal. This procedure also offered the possibility of removing any co-existing gallbladder stones.
Both of these studies reported a high level of technical success of 84% and 88%, respectively. Jung et al. (8) were able to remove concomitant gallbladder calculi in 89% of patients. Although Lim et al. (9) only removed present gallbladder calculi in 68% of patients, this was largely because a significant proportion of their patient cohort was younger and proceeded to have a LC. No severe procedure-related complications occurred. Minor complications, which did not require further intervention, included pain, haemobilia, bile leakage, and a transient rise in serum amylase. Jung et al. recorded a mean follow-up time of 644 days, in which time 12 patients (10.5%) developed a recurrence of CBD stones. In nine of these cases, the CBD stones were considered to be de novo lithiasis.
The other two included studies (10,11) included patients who underwent transcystic balloon dilatation of the ampulla and expulsion of CBD stones into the duodenum. As above, a standard ultrasound-guided cholecystostomy was performed for immediate biliary drainage. After an interval of typically 6–7 days, the drainage catheter was then exchanged for a guide wire, allowing the placement of a sheath within the gallbladder. A catheter, following the guide wire, was then introduced through the cystic duct and into the CBD then into the duodenum. The ampulla was then successively dilated to allow successful passage of the CBD stone. A balloon was then positioned proximal to the stone and partially or fully inflated and used to push the stone into the duodenum through the papilla, with the maximum diameter of the dilated balloon depending on the largest diameter of the CBD. A drainage catheter was then kept on free drainage within the CBD for a period of at least one month in order to reduce the risk of biliary peritonitis.
A similar level of technical success was achieved with rates of 89% and 100%. During these cases, no attempts were made to remove associated gallbladder calculi. There was a single case of bile peritonitis that required percutaneous catheter drainage.
A summary of the combined results of all the studies is shown in Table 1. In all the studies, technical success was defined as complete clearance of the CBD, which was proven on cholangiography. All procedures were performed under conscious sedation. The average length of the procedure was not recorded in any of the studies. A summary of the characteristics of each study included is shown in Table 2.
Summary of combined study results.
CBD, common bile duct.
Characteristics and results of the included studies.
CBD, common bile duct; CD, cystic duct; GB, gallbladder; PC, percutaneous cholecystostomy.
Discussion
The principal findings of this review are that percutaneous CBD and gallbladder stone extraction or expulsion via the cystic duct after PC may be a safe and effective option in patients who are not suitable for surgical intervention. There is no demonstrable difference in the efficacy of either procedure within these small, retrospective observational studies.
Cholecystostomy has become a common interventional radiology (IR) procedure for those not fit for LC and this additional procedure performed through the same tract may have potential for significant impact on patient care. Although PC alone offers an opportunity for infection source control and biliary drainage, it does not offer a solution to the underlying pathology of gallbladder calculi or for the management of choledocholithiasis. Through the ability to enter the tract already created by the PC, the option for the definitive treatment of CBD stones and removal of gallbladder stones has the potential to significantly decrease readmission rates and inpatient mortality as well as increase quality of life. Recent studies have demonstrated that a high proportion of patients are readmitted with recurrent gallstone related disease after PC (12), so a more definitive management solution may provide an opportunity to reduce also bringing financial benefits with minimal additional consumable costs.
The skill set required to perform the procedure is similar to standard biliary work and part of the established and common IR skill set, particularly for those who regularly perform percutaneous transhepatic cholangiography or similar procedures, with no particular specialist equipment or technically challenging steps. The technical success rates of the studies included in this review are slightly lower than the success rates commonly reported in other procedures. Successful removal of CBD stones with ERCP and sphincterotomy is typically in the range of 85%–95% (13,14). Although ERCP may be performed under sedation, many patients would not be suitable for or may refuse the procedure. Factors such as previous surgery or the presence of peri-ampullary diverticula may also make ERCP technically challenging. As well as this, ERCP is associated with a high risk of complications, such as pancreatitis, cholangitis, bleeding, and perforation. Recent literature (15) has demonstrated an ERCP-related complication rate of over 10% in elderly patients with choledocholithiasis.
The common practice during our biliary interventions would be to wait for up to one month before performing tract dilation or placing large sheaths through which to extract stones in order to allow for tract maturation, and minimize the risk of losing the access to the gallbladder, or causing bile peritonitis. The authors of the studies within this review typically waited around seven days before performing further intervention. However, they did then leave the PC drainage catheter in place for at least one month after stone treatment in order to allow tract maturation and minimize the risk of bile peritonitis before discontinuing the drain.
A transhepatic approach for the removal of CBD stones has also been shown to be an effective option for the treatment of CBD stones with success rates in the range of 93%–100% (16,17). However, a percutaneous transhepatic approach would involve the creation of a further tract with additional risk of biliary leak and has its own inherent risk due to the requirement of damage to the hepatic artery during the percutaneous puncture. This is further complicated if the patient has presented severely unwell with ACC, as the initial PC will still be required for infection source control. Therefore, if a patient is severely unwell and is deemed to not be a surgical candidate, a PC may be performed followed by a transcystic removal of CBD and/or gallbladder stones.
The studies included in this review are all retrospective observational cohort studies with a small sample of patients. All are at risk of significant selection bias and the results may not be directly applicable to a wider population. This is as a result of the procedures typically being performed within a single or small number of tertiary centers by experienced interventional radiologists. While, ideally, a prospective randomized controlled trial could be introduced to investigate this matter further, this would be logistically and ethically challenging. Instead, the establishment of a registry is recommended, so that the IR community may accumulate collective experience from multiple centers and physician operators in order to further analyze the efficacy and complication rates generalizable to an ever larger number of patients and centers.
Conclusion
Percutaneous CBD and gallbladder stone extraction or expulsion via the cystic duct after PC may be a safe management option for elderly or co-morbid patients who are not appropriate for surgical intervention. The procedure has the potential to significantly reduce readmission rates and associated patient morbidity and mortality. However, there is currently a paucity of high-quality research analyzing the beneficial impact. Currently, there are only a limited number of small volume retrospective observational studies available and prospective randomized controlled trials are required to assess this further.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
