Cholecystostomy Drains in the Unwell Patient

Disclaimer

This article is written for educational and professional discussion purposes from an Upper GI perspective. A fictitious patient is used to illustrate clinical decision-making and improve accessibility for non-medical readers. It does not constitute individual medical advice. All clinical decisions should be made within local policies, multidisciplinary frameworks, and patient-specific contexts.

Introduction

Acute calculous cholecystitis is typically managed with early laparoscopic cholecystectomy. However, this standard rapidly unravels in patients who are physiologically unstable, frail, or burdened by significant comorbidity. In such cases, percutaneous cholecystostomy (PC) is frequently employed as an alternative strategy to control sepsis and defer definitive surgery.

To ground this discussion, consider Mr Joe Bloggs, a fictitious 79-year-old man with severe chronic obstructive pulmonary disease, ischaemic cardiomyopathy, and type 2 diabetes. He presents with fever, right upper quadrant pain, and confusion. Imaging confirms acute calculous cholecystitis. Despite optimal resuscitation, his cardiorespiratory reserve renders him unfit for emergency surgery. The multidisciplinary team therefore opts for a cholecystostomy drain.

Mr Bloggs represents a common and growing cohort within acute surgical services, and his case illustrates both the utility and limitations of cholecystostomy drainage.

Indications and Rationale for Cholecystostomy

Contemporary international guidance supports cholecystostomy in patients with severe acute cholecystitis and organ dysfunction, or where operative risk outweighs benefit (Okamoto et al., 2018). Importantly, practical clinical experience closely mirrors these guideline-based indications.

In day-to-day Upper GI practice, the drivers for cholecystostomy insertion are consistently the same: physiological instability, sepsis refractory to antibiotics, and an operative risk profile that renders emergency cholecystectomy unsafe.

In Mr Bloggs’ case, the indication is archetypal rather than exceptional. This alignment between guidelines and real-world practice reinforces that cholecystostomy is not an ad hoc solution, but a predictable response to a recognisable clinical scenario. The primary aim remains rapid gallbladder decompression, infection control, and physiological stabilisation—not definitive treatment.

Technique: Why the Seldinger Approach Matters

Modern cholecystostomy drains are almost universally inserted using the Seldinger technique, a stepwise method designed to minimise tissue trauma. Under ultrasound guidance, a fine needle accesses the gallbladder, bile aspiration confirms position, and a soft guidewire is introduced. The access tract is gently dilated before placement of a pigtail catheter, which is anchored internally.

For Mr Bloggs, this technique is not merely procedural preference but risk mitigation. Compared with direct trocar insertion, the Seldinger technique is associated with lower rates of bleeding, organ injury, and bile leakage—advantages that are particularly relevant in elderly, septic, or anticoagulated patients (Bhatia et al., 2017; Patel et al., 2021).

Route of Insertion: Transhepatic Versus Transperitoneal

The two principal approaches to cholecystostomy insertion are transhepatic and transperitoneal, each with distinct risk profiles.

In Mr Bloggs’ case, a transhepatic approach is selected. Traversing a short segment of liver parenchyma stabilises the catheter and reduces bile leakage, an advantage supported by contemporary outcome data (van Overhagen and Meyers, 2019). The trade-off is an increased bleeding risk, which necessitates careful pre-procedure assessment of coagulation.

A transperitoneal approach may be preferable in patients with significant coagulopathy or ascites, but it carries a higher likelihood of bile leak and drain migration. The decision is therefore pragmatic rather than prescriptive, reflecting anatomy, physiology, and operator judgement.

Drain Type and Practical Management

Most cholecystostomy drains are 8–12 French pigtail catheters. Smaller drains risk blockage, while larger catheters increase discomfort without clear outcome benefit (Ahmed et al., 2018). Regular flushing protocols are commonly employed, although robust evidence guiding optimal aftercare remains limited.

For Mr Bloggs, nursing management is central to success. Drain output, fixation, and early recognition of complications influence outcomes—highlighting that cholecystostomy is as much a multidisciplinary intervention as a technical one.

Complications: A Procedure That Is Not Benign

Although often perceived as “low-risk,” cholecystostomy carries meaningful complication rates. Adverse events include bleeding, bile leakage, drain dislodgement, persistent sepsis, and recurrent biliary episodes (Elmunzer et al., 2017).

Mortality following cholecystostomy is usually driven by underlying frailty rather than procedural failure. Mr Bloggs improves clinically within 48 hours, but his admission underscores a critical reality: cholecystostomy modifies risk—it does not abolish it.

Assessing Drain Patency: Cholangiography Versus Clinical Testing

While cholangiography via the cholecystostomy drain is often described as standard practice prior to drain removal, real-world application is more nuanced. From practical Upper GI experience, routine cholangiography is not always necessary. Instead, a clinically guided approach is frequently adopted.

In Mr Bloggs’ case, the drain is capped after clinical improvement. He is closely observed for recurrence of right upper quadrant pain, fever, or biochemical deterioration. The absence of symptoms suggests adequate cystic duct patency and effective gallbladder decompression.

This approach reflects emerging evidence that clinical tolerance of drain capping is a reasonable surrogate marker for functional biliary drainage, particularly in patients for whom further invasive testing adds little value (Patel et al., 2021; Sutcliffe et al., 2020).

Recent studies suggest that selective rather than routine cholangiography does not increase adverse outcomes and may reduce unnecessary interventions, especially in frail populations (Ahmed et al., 2018). This pragmatic strategy aligns patient comfort, resource utilisation, and clinical safety.

Duration of Drain Placement

There is no universal consensus on optimal drain duration. Most centres advocate 4–6 weeks, allowing resolution of inflammation and maturation of the tract (Patel et al., 2021).

For Mr Bloggs, the drain remains in situ for six weeks.

During this period, he avoids further septic episodes but experiences reduced mobility and anxiety related to the external device—an often under-recognised burden that must be factored into shared decision-making.

Timing and Feasibility of Interval Cholecystectomy

For patients who recover sufficiently, cholecystostomy is best viewed as a bridge to interval cholecystectomy, typically at 6–12 weeks (Sutcliffe et al., 2020). Early surgery risks technical difficulty, while excessive delay increases recurrence risk.

When Mr Bloggs is reassessed, persistent respiratory limitation and functional decline lead to a shared decision not to proceed with surgery.

This outcome is common: many patients undergoing cholecystostomy never receive definitive cholecystectomy, transforming a temporary measure into long-term management by default.

Is Cholecystostomy Ever Definitive?

In practice, yes—but often by necessity rather than design. For patients with irreversible frailty or limited life expectancy, cholecystostomy may represent the least harmful option.

However, this shifts morbidity from operative risk to chronic device management and recurrent admissions (Ahmed et al., 2018).

Mr Bloggs’ case illustrates the ethical and clinical tension inherent in cholecystostomy use: it solves the immediate problem while exposing the limits of intervention.

Conclusion

Cholecystostomy drains play a vital role in the management of acute cholecystitis in unwell patients, but they are neither trivial nor definitive.

Practical experience confirms that the indications described in guidelines accurately reflect real-world use. Similarly, selective clinical assessment—such as drain capping—can safely replace routine cholangiography in appropriate patients.

Used judiciously, cholecystostomy is a bridge to stability. Used passively, it risks becoming a cul-de-sac.

Mr Bloggs’ journey highlights a central truth of high-risk surgery: the question is rarely what is ideal, but what is proportionate.

References

Ahmed, M., Diggory, R. and Reddy, S. (2018) ‘Percutaneous cholecystostomy: indications, technique and outcomes’, Clinical Radiology, 73(8), pp. 711–719.

Bhatia, S., Sivakumar, J. and Keshava, S.N. (2017) ‘Image-guided percutaneous interventions using the Seldinger technique’, Indian Journal of Radiology and Imaging, 27(4), pp. 429–437.

Elmunzer, B.J., Taylor, J.R., Scheiman, J.M. and Kane, S.V. (2017) ‘Percutaneous cholecystostomy for acute cholecystitis: outcomes and limitations’, Clinical Gastroenterology and Hepatology, 15(6), pp. 920–928.

Okamoto, K., Suzuki, K., Takada, T. et al. (2018) ‘Tokyo Guidelines 2018: management of acute cholecystitis’, Journal of Hepato-Biliary-Pancreatic Sciences, 25(1), pp. 55–72.

Patel, N., Oto, A. and Thomas, S. (2021) ‘Safety and efficacy of ultrasound-guided percutaneous biliary interventions’, Abdominal Radiology, 46(9), pp. 4201–4212.

Sutcliffe, R.P., Hollyman, M. and Hodson, J. (2020) ‘Management strategies for acute cholecystitis in high-risk surgical patients’, HPB, 22(12), pp. 1651–1659.

van Overhagen, H. and Meyers, H. (2019) ‘Percutaneous gallbladder drainage: technical considerations and outcomes’, CardioVascular and Interventional Radiology, 42(2), pp. 190–198.