This new column summarizes patient cases posted to SIR Connect, SIR’s popular online member community, the responses from other SIR members, and how that feedback helped the original poster. To see how SIR’s online community can help you, visit SIR Connect at connect.sirweb.org. SIR thanks Sudhen B. Desai, MD, for his assistance with this article.
We seem to be seeing more patients for perc cholecystostomy who are “poor operative candidates” and will never go on to definitive cholecystectomy. What are your thoughts on D/Cing them after >8 weeks with resolution of symptoms and patent cystic duct and CBD and a intact tube track upon dye injection, in transhepatic vs. subhepatic/direct GB approach?
Comments
There were many thoughtful responses—no single all-inclusive, definitive response. The aggregate of knowledgeable responses and insights allowed me to develop a consensus solution to my clinical dilemma, which is usually the best approach to solve problems. Furthermore, the general sharing of experiences and knowledge is both a reaffirming and learning experience, both of which are important— i.e., it takes a village...
Although my question didn’t pertain to an individual patient, the responses led my practice to change how we treat these patients. My conclusions from the discussion online are as follows:
- Surgeons are less apt to operate nowadays on gallbladders and percutaneous cholecystectomy requests are increasing.
- The responsibility for follow-up and/or patient direction/definitive therapy falls on IR.
- A transhepatic approach to the gallbladder (hopefully via bare area) is preferred but not mandatory (any port in a storm).
- Cholecystectomy is the definitive therapy but is less likely to occur in this patient population.
- Therefore, the IR should do a follow-up cholangiogram in 8 weeks (a hepatobiliary [HIDA] scan only in cases of doubt).
- If cystic duct/common bile duct (CBD) patent, clamp tube for 1–2 weeks and D/C tube if tolerated well for both calculous and acalculous cholecystitis patients with counseling of risk for the former.
- If duct occluded, continue drainage with Q 2–3 month tube changes with cholangiograms to assess for a).
- Not personally comfortable with literature support, techniques and outcomes for stone removal/gallbladder ablation at this time.
- Make sure patients aren’t lost to follow-up and encourage surgeons to operate on a delayed basis. In some patients the tube may have dislodged and the IR is unable to recannulate the track. If the gallbladder can’t be accessed percutaneously as it is decompressed/scarred, they may have to operate emergently.
- Many of these patients will have lifelong tubes.
