Transhepatic or Transperitoneal? Choosing the Route for Percutaneous Cholecystostomy
Chọc dẫn lưu túi mật qua da (percutaneous cholecystostomy – PC) là phương pháp can thiệp quan trọng trong điều trị viêm túi mật cấp do sỏi hoặc do u ở những bệnh nhân không đủ điều kiện phẫu thuật cắt túi mật ngay. Hiện nay, có hai đường tiếp cận chính để thực hiện PC: xuyên gan (transhepatic) và xuyên phúc mạc (transperitoneal). Việc lựa chọn đường vào phụ thuộc vào đặc điểm giải phẫu, tình trạng lâm sàng, yếu tố kỹ thuật và nguyên nhân nền của viêm túi mật.
Hướng dẫn của các hội chuyên ngành lớn như World Society of Emergency Surgery (WSES), Italian Society of Geriatric Surgery (SICG) và Society of Interventional Radiology (SIR) đều công nhận cả hai phương pháp, nhưng ưu tiên đường xuyên gan trong do nguy cơ rò mật thấp hơn, đường hầm ống dẫn lưu vững chắc hơn và thời gian hình thành đường hầm nhanh hơn. Tuy nhiên, đường xuyên gan lại có nguy cơ chảy máu cao hơn, đặc biệt ở bệnh nhân rối loạn đông máu hoặc bệnh gan nặng, khi đó đường xuyên phúc mạc là lựa chọn thay thế phù hợp.
Vậy: “Ngoài ra còn có các yếu tố gì khác ảnh hưởng lựa chọn dẫn lưu túi mật ra da xuyên gan và xuyên phúc mạc? Sự khác biệt về lợi ích, nguy cơ, kết cục, thời gian lưu ống và biến chứng giữa 2 phương pháp?”
II. INDICATIONS, CONTRAINDICATIONS,
AND TECHNICAL CONSIDERATIONS
1. Indications and Contraindications
Percutaneous
cholecystostomy is indicated in adults
with moderate to severe acute cholecystitis who are at high surgical
risk due to comorbidities, advanced age, or critical
illness, and in whom medical management has failed or surgery is
contraindicated.[1-3] This
includes both calculous and malignant cholecystitis. The WSES and SICG
recommend PC as a temporizing or definitive measure in such patients, with the transhepatic
approach as the preferred method except in specific contraindications.[1][3]
The transhepatic
approach is specifically indicated for most patients, especially
those with ascites, those requiring stable or long-term drainage
(such as in malignant cholecystitis), and those in whom a secure tract is
desired.[1][3] Contraindications
to the transhepatic approach include uncorrectable coagulopathy, severe
thrombocytopenia, advanced liver disease (e.g., cirrhosis with portal
hypertension), anatomical inaccessibility of the gallbladder through the
liver, and the presence of large hepatic tumors or metastases along the
intended tract.[1][4]
The transperitoneal
approach is indicated in patients with severe liver disease or
uncorrectable coagulopathy, those with a floating or ectopic gallbladder,
or when hepatic tumors preclude a safe transhepatic route.[1][4] Contraindications
to the transperitoneal approach include significant ascites, high
risk for catheter dislodgement, and the need for prolonged drainage,
as the transperitoneal tract matures more slowly and is less stable.[1][3]
2. Technical Factors: Imaging
Guidance, Catheter Size
Imaging guidance is
essential for both approaches, with ultrasound (US) and computed
tomography (CT) being the most commonly used modalities. The SIR and
WSES recommend image guidance for all PC procedures to optimize safety
and accuracy, regardless of the anatomical approach.[2-3][5] Catheter sizes of
8.5–10 French are preferred to minimize the risk of tube dislodgement
and clogging, with self-retaining catheters recommended for both
approaches.[2][5]
The choice between the
trocar and Seldinger techniques for catheter insertion also influences
outcomes. The trocar technique is associated with fewer
complications, shorter procedural time, and less postprocedural pain, while
the Seldinger technique allows for more controlled wire-guided
placement but may have a higher rate of bile leak and abscess
formation.[6]
COMPARATIVE BENEFITS, RISKS, AND
CLINICAL OUTCOMES
1. Technical Success, Symptom
Relief, and Infection Control
Both transhepatic and
transperitoneal approaches demonstrate high technical success rates,
typically exceeding 85–90%, and are effective in achieving rapid
symptom relief and infection control in acute cholecystitis,
regardless of etiology.[4-5][7-11] The
SIR defines technical success as successful drain placement with free
flow of bile, and clinical success as resolution of sepsis or reduction
in mortality, both of which are achieved at high rates with either
approach.[2]
2. Comparative Risks and
Complications
The transhepatic
approach is associated with a significantly higher risk of bleeding
compared to the transperitoneal approach. In a meta-analysis of 684
patients, the risk of bleeding was 6.3% for the transhepatic approach
versus 1.6% for the transperitoneal approach (odds ratio 4.02, p=0.004).[4] This risk is
particularly relevant in patients with coagulopathy or liver disease. Conversely,
the transhepatic approach provides a more stable tract, reducing the
risk of bile leak and catheter dislodgement, and is preferred in
patients with ascites or those requiring prolonged drainage.[1][3-4][7]
Bile leak
is more common with the transperitoneal approach, as the liver
parenchyma in the transhepatic route provides a tamponade effect and
facilitates tract maturation. In a multicenter analysis, all bile leaks
occurred with the transperitoneal approach and none with the transhepatic
approach (p=0.001).[12] However,
other studies and meta-analyses have not found statistically significant
differences in bile leak rates, though the trend favors the transhepatic
approach.[4-5][8]
Catheter dislodgement rates
are similar between the two approaches, with a theoretical advantage for the
transhepatic route due to the longer intrahepatic tract, but this has not been
consistently demonstrated in clinical studies.[5][8] Other
complications, such as pain, infection, abscess formation, and hollow viscus
injury, do not differ significantly between the two approaches.[4-5][8]
3. Long-Term Outcomes and
Patient-Reported Outcomes
Long-term outcomes,
including recurrence of cholecystitis, need for repeat intervention, and
quality of life, are not significantly different between the
transhepatic and transperitoneal approaches.[4-5][8][13-14] The
risk of recurrence is more closely related to patient factors
such as underlying malignancy, presence of common bile duct stones, and
duration of drainage, rather than the technical approach used.[14] Quality of
life is negatively impacted by the presence of a cholecystostomy
tube, regardless of approach, but improves after tube removal or
definitive surgical management.[15-16]
Pain scores
during and after the procedure may be slightly lower with the transhepatic
approach, as demonstrated in a retrospective study where mean pain scores
during puncture were 3.1 for transhepatic versus 4.5 for
transperitoneal (p=0.001), and at 12 hours post-procedure were 1.5 versus 2.2,
respectively (p=0.001).[7] However,
meta-analyses and larger studies have not found significant differences
in pain or patient satisfaction between the two approaches.[4-5]
4. Special Populations:
Immunocompromised and Severely Comorbid Adults
In immunocompromised
adults and those with severe comorbidities, both approaches are effective,
with high technical and clinical success rates.[1-2][8][17] The
transhepatic approach is generally preferred due to its lower risk of bile leak
and more secure catheter tract, unless severe liver disease or uncorrectable
coagulopathy is present, in which case the transperitoneal approach is
indicated.[1-2][4] The
majority of adverse outcomes in these populations are related to
underlying comorbidities rather than the procedural approach itself.[2][9][17]
5. Impact on Interval
Cholecystectomy
Both transhepatic and
transperitoneal approaches are feasible and safe as bridges to interval
cholecystectomy in adults with calculous cholecystitis. The transhepatic
approach may offer technical advantages during subsequent surgery,
including shorter operative times, less intraoperative bleeding, and shorter
hospital stays, but may be associated with more severe adhesions at the
puncture site.[7] The
transperitoneal approach is associated with less local bleeding and
less severe adhesions but longer operative times and greater blood loss. Critically,
there are no significant differences between the two approaches in terms
of conversion to open surgery, rate of subtotal cholecystectomy, or major
complications.[7-9]
DURATION OF CATHETER DRAINAGE AND
POST-PROCEDURAL MANAGEMENT
The recommended
duration of catheter drainage following percutaneous cholecystostomy in
adults with calculous cholecystitis is generally 3–6 weeks, with removal
guided by clinical improvement and confirmation of biliary tree patency,
as endorsed by the WSES and SICG.[1][3][18-19] In
malignant cholecystitis, longer or indefinite drainage may be
required, depending on the persistence of obstruction and the patient’s overall
prognosis.[11][14] There
is no compelling evidence that the optimal duration of drainage differs between
transhepatic and transperitoneal approaches, as tract maturation and clinical
factors are the primary determinants.[1][3][7][19]
A systematic review
found that the mean time to tube removal was more than four weeks in
most studies, with earlier removal considered only in select cases with rapid
clinical improvement and low risk of complications.[19] In patients with
underlying malignancy or common bile duct stones, a duration of PC
shorter than 44 days was associated with a higher risk of recurrence of
cholecystitis, and maintaining the catheter for at least six weeks is
recommended.[14] Clamping
the tube for 1–2 weeks before removal may further reduce recurrence risk.[14]
RARE AND LONG-TERM COMPLICATIONS
Rare and long-term
complications, such as chronic fistula, persistent drainage, and late tumor
seeding, are not uniquely associated with either the transhepatic or
transperitoneal approach. The risk of these complications is low for
both approaches and is more closely related to patient factors, underlying
biliary pathology, and duration of catheterization than to the anatomical
route of drainage.[13][15][20] Tumor
seeding along the catheter tract is a theoretical concern in malignant
cholecystitis, particularly with the transperitoneal approach, but has not been
reported as a clinically significant complication in the literature.[4][8][15][20]
COST-EFFECTIVENESS, RESOURCE
UTILIZATION, AND PRACTICE PATTERNS
There is no direct
evidence from the literature to support a clinically meaningful difference in
cost-effectiveness or overall resource utilization between transhepatic and
transperitoneal percutaneous cholecystostomy in adults with calculous or
malignant cholecystitis.[3-5][8] Both
approaches are associated with low rates of major complications, similar
technical complexity, and comparable need for repeat intervention or additional
resource use. The WSES notes that the transhepatic approach is
generally preferred due to technical advantages and reduced risk of bile leak,
and also refers to "ease and reduced costs" when comparing
percutaneous transhepatic gallbladder drainage to other drainage modalities,
but not specifically to the transperitoneal approach.[3]
Regional and
institutional practice patterns can influence the choice between transhepatic
and transperitoneal approaches, but outcomes are comparable when procedures are
performed according to established technical standards and patient selection
criteria.[1-2][5][8][21] The
most important determinants of success and safety are technical factors,
operator experience, and adherence to evidence-based protocols, rather than
regional or institutional preferences for a particular approach.
GUIDELINE RECOMMENDATIONS AND
CLINICAL IMPLEMENTATION
The World Society of
Emergency Surgery and the Italian Society of Geriatric Surgery recommend the transhepatic
approach as the preferred method for percutaneous cholecystostomy in both
elderly and general adult populations, except in the presence of severe
liver disease or coagulopathy, or when the gallbladder is not accessible
through the liver.[1][3] The
Society of Interventional Radiology also supports the transhepatic route as
first-line, with the transperitoneal approach reserved for specific
contraindications.[2] Both
approaches are considered safe and effective, with the choice individualized
based on patient anatomy, comorbidities, and operator experience.
ACTIONABLE RECOMMENDATIONS
For adult patients with
acute cholecystitis due to gallstones or tumors who are not suitable for
immediate cholecystectomy, percutaneous cholecystostomy should be performed
using the transhepatic approach whenever feasible, as it offers lower risk of
bile leak, more secure catheter tract, and faster tract maturation. The
transperitoneal approach should be reserved for patients with severe liver
disease, uncorrectable coagulopathy, or anatomical inaccessibility of the
gallbladder through the liver. Both approaches require image guidance
(ultrasound or CT), with catheter sizes of 8.5–10 French
preferred. Operator experience is critical for optimizing outcomes.
The recommended
duration of catheter drainage is 3–6 weeks for calculous cholecystitis, with
removal guided by clinical improvement and confirmation of biliary tree
patency. In malignant cholecystitis, longer or indefinite drainage may be
required. There is no significant difference in long-term outcomes,
recurrence rates, or quality of life between the two approaches. Rare and
long-term complications are not uniquely associated with either approach.
