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Friday, April 24, 2020

Cystic Duct Embolization with Chemical Gallbladder Ablation for the Treatment of Acute Calculous Cholecystitis in High-Risk Patients: A Prospective Single-Center Study


Clinical question

Can cystic duct embolization followed by chemical gallbladder ablation provide an alternative to permanent external drainage for non-surgical patients with calculous cholecystitis?

Take-away point
In non-surgical patients with calculous cholecystitis treated with permanent external drainage, coil cystic duct embolization followed by chemical ablation with a sclerosing agent can facilitate eventual catheter removal.

Reference

Atar E, Khasminsky V, Friehmann T, Choen A, Bachar GN. Cystic Duct Embolization with Chemical Gallbladder Ablation for the Treatment of Acute Calculous Cholecystitis in High-Risk Patients: A Prospective Single-Center Study. J Vasc Interv Radiology. 2020; 31:644-648

Click here for abstract

Study design
Single Arm, Prospective Cohort study

Funding
No reported Funding

Setting
Single Center, Academic Hospital. Rabin Medical Center, Tel Aviv University, Israel






Figure. An 80-year-old man with acute calculous cholecystitis who was ineligible for surgery because of severe comorbidities. (a) Cholangiography via the gallbladder drain demonstrates gallstones in the gallbladder but not in the common bile duct (arrow). (b) The cystic duct is blocked by means of Nester coils (arrow). (c) Gallbladder ablation is performed via the gallbladder drainage tube tract (arrow). (d) On fuoroscopy performed after 1 month, the gallbladder is still shrunken (arrow), and the drain is removed. (e) On ultrasound performed after 3 months, the gallbladder is shrunken and filled with stones (arrow).

Summary


Standard treatment for calculous cholecystitis is surgical cholecystectomy, however in elderly patients with high risk comorbidities there is increased morbidity and mortality after cholecystectomy. Percutaneous cholecystostomy provides a bridge or definitive therapy, however, eventual tube removal is associated with recurrent cholecystitis and prolonged percutaneous drainage requires follow-up maintenance procedures and is associated with decreased quality of life.

In this study, the authors demonstrate that following percutaneous cholecystostomy tube placement, cystic duct embolization followed by chemical gallbladder ablation is a viable alternative to definitive external drainage. 10 non-surgical patients were enrolled and underwent urgent cholecystostomy tube placement for acute cholecystitis. Nine (9) of the patients proceeded to have cholangiography via the external drain with any biliary duct stones successfully pushed into duodenum. A 10-Fr multipurpose drainage catheter was left in place, bridging the cystic duct to the duodenum to avoid future cannulation of cystic duct. After an asymptomatic interval period of 2-3 weeks, patients were considered for cystic duct coil embolization. A capped external drain was left in gallbladder with the option of drainage for symptomatic patients. After an additional asymptomatic interval of 3 weeks, cystic duct occlusion was confirmed with cholangiography followed by chemical gallbladder ablation with 3% aethoxysklerol. Interval sonography 3 weeks following this was performed to confirm gallbladder collapse (<25mm) and pericholecystic fluid absence. External drains were removed if asymptomatic. If gallbladder was >25mm, patient kept external drain for another 3 weeks with periodic sonography.

9 of 10 patients successfully proceeded with the full series of drainage, embolization, and ablation. After coil embolization, cholangiography on patient 1 demonstrated contrast spillage along the drain with transcolonic passage of contrast. This patient was initially planned for subsequent ablation, however the gallbladder remained non-dilated and the patient asymptomatic so no additional intervention was performed. Patient 2 experienced coil migration (4mm-5mm diameter) into the common bile duct. The coil was snared and replaced with a larger-caliber coil (8 mm). Patient 3 had undergone prior cystic duct embolization and gallbladder ablation, that resulted with subcutaneous leaks at previous the access site. Repeat cholangiography demonstrated intact cystic duct embolization and the patient requested repeat chemical ablation, which was successful. Patient 8 had continuous gallbladder secretions despite multiple ablations. A drain was left in place until secretions ceased and the drain was eventually removed. The patient was asymptomatic for 9 months.

Sonography was performed at 1 month after external drain removal for all patients. Patients were followed by their own surgeons or family physicians with return to Vascular Radiology only if needed. 3 of the 10 patients were reported as deceased during the follow up period due to unrelated causes with minimum follow up time of 7 months.

Commentary


Non-surgical patients with cholecystotomy tubes in place have decreased quality of life and require, at minimum, interval procedures for routine catheter maintenance. This paper introduces the concept of a “percutaneous cholecystectomy” via cystic duct embolization followed by chemical gallbladder ablation. None of the patients experienced short or long-term complications; however, several patients had persistent external bilious drainage up to 14 months after the procedure. So while technically feasible, the procedure requires further refinement and comparison to other methods of ablation. 

Post authors
Lucas Fass, BS - Rush Medical College 2021 MD Candidate
Lucas_fass@rush.edu

Joshua Okero, BS - Rush Medical College 2023 MD Candidate 

David M Tabriz
Assistant Professor
Department of Vascular & Interventional Radiology
Rush University Medical Center, Chicago, IL
@DrDaveTabriz

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