Rare complications after percutaneous transhepatic gallbladder drainage for acute cholecystitis: a case description
Executive Summary
This briefing document examines a rare case of complex, late-onset complications following percutaneous transhepatic gallbladder drainage (PTGBD) in a patient with acute calculus cholecystitis (AC). While PTGBD is generally considered a safe, less invasive alternative to early laparoscopic cholecystectomy (LC) for high-risk surgical patients, this case identifies significant risks associated with prolonged drainage in patients on antithrombotic therapy.
Critical findings include:
Late-Onset Complications: Development of an intramural duodenal hematoma (IDH) and an internal fistula between the gallbladder and the IDH occurred nearly one month after the initial PTGBD procedure.
Diagnostic Markers: Diagnosis was facilitated by endoscopic ultrasonography and cholangiography via the PTGBD tube, which revealed the internal fistula and gastric outlet obstruction.
Treatment Limitations: While conservative management is standard for IDH, surgical intervention became necessary due to gangrenous gallbladder changes, bile leakage into the hematoma, and failed conservative management of the gastric outlet obstruction.
Risk Factors: Dual-antiplatelet therapy and the mechanical irritation of the drainage tube were primary drivers of the iatrogenic complications.
Alternative Strategies: Endoscopic transpapillary gallbladder drainage (ETGBD) or endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) are advocated as safer alternatives for patients with high bleeding risks.
Clinical Profile and Initial Presentation
Patient Background
The case involves a 68-year-old male with a significant medical history including:
Recent Surgery: Coronary artery bypass grafting (CABG) performed 80 days prior.
Current Medication: Dual-antiplatelet therapy (aspirin 100 mg/day and clopidogrel 75 mg/day).
Clinical Status: American Society of Anesthesiologists physical status (ASA-PS) classification level IV.
Initial Diagnosis and Management
The patient presented with right upper quadrant pain, fever (38.5 ℃), and a positive Murphy’s sign.
Laboratory Findings: WBC 12.9×10⁹/L; Hemoglobin 97 g/L; PT-INR 1.49.
Imaging: Plain CT showed gallbladder enlargement with multiple luminal stones and a wall thickness of 2.4 mm.
Primary Strategy: Due to high surgical risk (recent CABG/antiplatelet therapy), early LC was contraindicated. Following 2018 Tokyo Guidelines, PTGBD was performed (8F pigtail catheter) alongside anti-infective therapy (piperacillin-tazobactam).
Secondary Presentation: Late-Onset Complications
Twenty-five days post-PTGBD, the patient returned with sudden epigastric pain and worsening vomiting. Despite bed rest and a low-fat diet, the patient remained on dual-antiplatelet therapy.
Diagnostic Findings
Pathogenetic Analysis
The source material postulates a specific mechanism for these rare complications:
Mechanical Irritation: The PTGBD tube exerted constant compression against the gallbladder wall.
Fistula Formation: This compression induced penetration and the formation of a fistula to the adjacent duodenal wall (specifically the intramural space, not the lumen).
Hemorrhage: The combined force of the fistula and shedding force triggered intramural bleeding, exacerbated by the patient's dual-antiplatelet therapy, leading to the formation of the IDH.
Surgical Intervention and Findings
While the majority of IDH cases recover with conservative treatment (fasting, parenteral nutrition, and antithrombotic therapy discontinuation), this patient required exploratory laparotomy due to failed conservative management and signs of cholangitis.
Intraoperative Observations
Gallbladder Status: Gangrenous changes were observed.
Hematoma Characteristics: A 6-cm diameter IDH located in the bulb and descending part of the duodenum. It contained a mixture of bile and hematoma.
Fistula Confirmation: An internal fistulous tract was confirmed between the gallbladder and the IDH.
Procedures Performed
Total Cholecystectomy: Removal of the gangrenous gallbladder and gallstones.
Distal Gastrectomy with Gastrojejunostomy: Conducted to prevent postoperative duodenal stricture and gastric emptying dysfunction.
Duodenal Drainage: A tube was placed in the descending portion of the duodenum to manage potential leakage from the duodenal stump.
Recurrence and Long-Term Outcome
Five days after the initial discharge (postoperative day 14), the patient presented with bleeding from the duodenal drainage tube.
Recurrent IDH: CT imaging revealed a new confined, hyperdense mass at the third part of the duodenum.
Management: This recurrence was successfully managed conservatively with supportive therapy over seven days.
Follow-up: At 12 months, the patient remained on aspirin monotherapy with no further complications.
Clinical Implications and Recommendations
Risks of PTGBD in High-Risk Patients
While bleeding is the most serious complication of PTGBD, it typically occurs during or shortly after the procedure. This case proves that bleeding and fistula risks persist as long as irritative factors (the drainage tube) remain, particularly in patients with coagulopathy or those on antithrombotic medications.
Preoperative Guidelines
Drug Discontinuation: Evidence suggests discontinuing aspirin 7–10 days and clopidogrel 5–7 days prior to traumatic procedures to mitigate bleeding risks.
Heparin Bridging: The source context notes that heparin bridging therapy is not recommended for antiplatelet therapy.
Recommended Alternatives
For patients with a high risk of bleeding, the 2018 Tokyo Guidelines suggest alternative drainage methods that may be safer than PTGBD:
ETGBD: Endoscopic transpapillary gallbladder drainage.
EUS-GBD: Endoscopic ultrasound-guided gallbladder drainage.
Conclusion
This case represents the first reported instance of recurrent IDH and internal fistula occurring nearly one month after PTGBD. It highlights the necessity for clinicians to exercise extreme caution when performing traumatic procedures on patients with high-risk bleeding profiles and to remain vigilant for late-onset iatrogenic complications.
