Thinking ahead: gallbladder intussusception following transperitoneal percutaneous cholecystostomy tube placement

Abstract

Percutaneous cholecystostomy (PC) is a common minimally invasive, image-guided procedure performed primarily on high-risk patients with acute cholecystitis for gallbladder decompression. Herein, we present a case of a patient undergoing PC placement using a transperitoneal approach. On subsequent upsizing attempts, the gallbladder fundus was found to invaginate during advancement of replacement drains, causing gallbladder intussusception. The use of a balloon and locked pigtail catheter were required to reposition the gallbladder to proper position. The patient’s planned percutaneous cholecystoscopy was delayed by 4 weeks until intended upsizing could be performed. This case demonstrates the advantage of achieving transhepatic gallbladder access to support tract formation and limit procedural complications.

Background

Percutaneous cholecystostomy (PC) is a common minimally invasive, image-guided procedure, which places a drainage catheter into the gallbladder lumen. It is performed primarily in high-risk patients with acute calculous cholecystitis (1.5% of total cases) or acute acalculous cholecystitis (7.4% of total cases) for gallbladder decompression.¹ Two percutaneous routes are available to access the gallbladder lumen: transhepatic and transperitoneal.² Historically, the transhepatic route has been favoured; however, the recent literature contests this dogmatic approach.³

Case presentation

An 89-year-old female nursing home resident was admitted to the intensive care unit for septic shock. CT revealed a distended gallbladder without wall thickening, containing three large stones measuring up to 3 cm and a smaller stone impacted at the gallbladder neck. A diagnosis of acute cholecystitis was made, and surgery was consulted and recommended PC placement by interventional radiology (IR) given multiple comorbidities and critical illness. On the same day as presentation, IR successfully placed an 8.5 French (Fr) Flexima drain under ultrasound and fluoroscopic guidance via transperitoneal access (figure 1A), with cholangiogram confirming CT findings. She recovered well, returning for PC drain upsize 4 weeks later in preparation for eventual stone removal via percutaneous cholangioscopic lithotripsy. At that time, the existing tube was removed over a 0.035-inch Amplatz stiff wire, and a new 12Fr all-purpose locking drain (APDL) was advanced under fluoroscopic guidance. During advancement of the APDL using light to moderate force, the drain tip met the gallbladder fundus, causing subsequent marked invagination of the gallbladder fundus into the gallbladder body (figure 1B).

Figure 1.

(A) Initial fluoroscopic image of an 8.5 French (Fr) Flexima drain (arrow) placed within the gallbladder. (B) Guidewire in place within the gallbladder lumen, with fundal invagination of the gallbladder fundus (arrows) following attempted placement of a 12Fr all-purpose drain. (C) Expanded 4 mm×4 cm balloon (arrow) within the gallbladder lumen. (D) Retracted balloon at fundal tip (arrow) with gallbladder fundus repositioned.

The 12Fr catheter was removed, and the gallbladder demonstrated persistent fundal invagination without spontaneous resolution. Over the wire, a 4 mm×4 cm balloon was advanced into the gallbladder lumen (figure 1C). Following inflation, the balloon was gently retracted to pull the fundus back into proper position (figure 1D). Recurrent invagination of the gallbladder occurred with additional attempts to dilate and advance the 12Fr catheter. Subsequently, a smaller 10Fr APDL was successfully advanced into the gallbladder lumen; however, there was reoccurrence of fundal invagination (figure 2A). The drain was then looped and locked in the gallbladder lumen (figure 2B), and used to pull the fundus laterally (figure 2C). On final imaging, the gallbladder fundus was in normal position, and contrast was noted to outline the liver capsule, incidentally confirming a transperitoneal course for the drain (figure 2D).

Figure 2.

(A) Fluoroscopic image demonstrating recurrent gallbladder fundal invagination (arrows) following placement of a 10 French (Fr) all-purpose drain. (B) Drain pigtail looped and locked in gallbladder lumen (arrow). (C) Locked all-purpose drain pulled back to replace gallbladder fundus. (D) 10Fr all-purpose drain in final position within gallbladder, with fundus in proper position. Of note, contrast outlines liver capsule (arrows), confirming drain’s transperitoneal course.

Outcome and follow-up

The patient remained stable following the procedure. T-Tack fixation of the gallbladder fundus was considered, though deferred to allow for tract maturation. Four weeks later, the patient’s PC drain was successfully upsized to a 12Fr APDL without intussusception during the procedure. The patient’s first session of percutaneous cholangioscopy with laser lithotripsy and stone removal was performed 2 weeks after drain upsize. At 6-month follow-up, the patient had undergone four additional sessions of cholangioscopy; however, PC drain was unable to be removed due to recurrent cholelithiasis.

Discussion

Although laparoscopic cholecystectomy remains the definitive treatment of AC, PC is a viable alternative that is increasingly used for gallbladder decompression, especially in non-surgical candidates.² Both transhepatic and transperitoneal routes are available for percutaneous access of the gallbladder lumen.² Historically, the transhepatic route has been favoured, given its purported advantages of reducing bile leaks, providing greater catheter stability and allowing quicker tract maturation.^{1 2} When the transhepatic route is limited (eg, anatomical reasons, liver disease and anticoagulation), a transperitoneal approach may be considered depending on the degree of gallbladder distention and proximity to the abdominal wall.^{1 2}

A 2019 retrospective analysis of 229 patients challenges the superiority of the transhepatic approach, indicating no difference in the incidence of bile leaks, associated bleeding, catheter displacement or length of time until catheter removal (as a marker of tract maturation) between techniques.³ This study did not report incidences of all factors known to prolong the time needed for tract formation, including steroid therapy, renal failure, severe malnutrition or uncontrolled diabetes mellitus.⁴ An older, prospective study comparing tract maturation between the procedural approaches demonstrated that 93% of patients had a mature tract 2 weeks after a transhepatic PC compared with just 13% of patients with a transperitoneal PC.⁴

This case report describes a complication associated with the transperitoneal approach for PC placement. Visualisation of the drainage catheter under fluoroscopy at the time of tube upsizing revealed the tube coursed through the peritoneal cavity and entered the gallbladder lumen through its fundus. This approach can be purposeful or inadvertent. In a cadaveric study examining unintentional peritoneal PC placements, it was discovered that 11 of 19 transhepatic punctures (58%) passed through the peritoneum instead of the liver’s bare area.⁵ Puncture of the free gallbladder wall in such cases may limit guidewire stability due to the absence of firm, supporting structures like the liver and bare area.⁵ The invagination of the gallbladder fundus in this report is thought to be related to the drain entering the free wall of the gallbladder from the peritoneum. As described, such a course may hinder or delay tract maturation and eliminate structural support from the liver parenchyma. Although this complication was not associated with bleeding or a persistent bile leak, it did impact patient care by delaying the rate of tube upsizing and subsequent planned percutaneous cholangioscopy with lithotripsy and stone removal. At our institution, drainage upsizing from 8Fr to 12Fr is standard of care and well tolerated by most patients. However, given the potential for complications such as described in this report, consideration could be made for stepwise drainage upsize (8Fr to 10Fr to 12Fr) for patients with transperitoneal PC placement.

Learning points.

• Percutaneous cholecystostomy (PC) is an increasingly used treatment for acute cholecystitis in high-risk patients.

• While studies indicate no difference in adverse outcomes or effectiveness between either transhepatic or transperitoneal approach during PC placement, the literature remains controversial regarding measures of tract maturation and guidewire stability, which are important factors for PC exchange.

• PC drain exchange can be complicated by gallbladder intussusception, secondary to the nature of a transperitoneal approach during initial PC placement.

• Consideration should be made for potential follow-up interventions (eg, drain upsizing in preparation for cholangioscopy) when selecting a proper PC approach given the risk of complications such as described in this report.