Ultrasound-Guided Drainage of the Gallbladder - SD

Introduction

Hello, my name is Fru.

I'm a radiologist and chief of ultrasound at Kaska University Hospital in Stockholm at Sweden.

Today's presentation will be about ultrasound guided drainage of the gallbladder or chole cystostomy.

This is a procedure that aims at decompressing gallbladder by insertion of a percutaneous drain tube.

We will briefly discuss indications for this procedure and patient preparation.

We'll follow a step by step guide to performing this procedure and we will take a quick look at common complications.

Enjoy.

Overview of the Procedure

Ultrasound guide at the percutaneous drainage of the gall bladder or co cystostomy is a minimal invasive procedure used to decompress the gallbladder.

Indications for the Procedure

Patients who undergo drainage of the gallbladder fall basically into two categories, those in which the procedure represents a bridge to surgery and those in which it is intended as a definitive treatment.

The patient in which gallbladder drainage represents a bridge to surgery is typically a patient who suffers or a gallbladder obstruction and is not a candidate to immediate surgical treatment.

Because of contraindications, the contraindications can depend on the patient general status.

For example, coagulation problems or local conditions such as paralytic infections.

These patients may undergo percutaneous sc cystotomy to decompress the obstructive gall bladder as a first temporizing measure and after the symptoms have subsided and the status is optimized, usually the definitive treatment will be cholecystectomy.

Ectomy, on the other hand, in acal cholecystitis or in patients with age or life expectancy does not allow surgical treatment.

Percutaneous coly cystostomy may be intended as a definitive treatment, whether the coly cystostomy is intended as a temporary or definitive measure in order to make it safe and worthwhile, it is mandatory for the radiologist to obtain relevant patient history.

For example, we must know if patient has undergo previous upper GI surgery or bi surgery and we must exclude contraindications.

Most of the contraindications are connected to patient coagulator status.

Thus, we must obtain a preoperative workup.

Naau institution, we only admit patients to this procedure if their blood count features a platelet count of more than 50,000, and if their activated pro thrombin time is of less than 40 seconds and their international normalized ratio is of less than 1.6, also we recommend preoperative antibiotic prophylaxis.

Approaches to Gallbladder Puncture

In order to fully grasp the details of this procedure, we need to be familiar with the two most common approaches to gall bladder puncture.

Let us imagine that this is the abdominal wall depicted in a section.

This is the liver and this green one is the gallbladder.

Transperitoneal Approach

The transperitoneal approach to co cystostomy entails that a drainage tube is inserted through the abdominal wall and through the peritoneum to reach the gallbladder and drain it.

At this point, a hole is made on the free wall of the gallbladder and through this hole, despite the presence of the drainage tube, a small bile leakage can be anticipated, especially when the gallbladder is the compressor then becomes more mobile.

Bile leakage is a inferior and potentially very dangerous complication of colonostomy because of two factors.

On one hand, the chemical properties of the bile, which is extremely irritating and causes a very painful chemical inflammation of the peritoneum.

And on the other hand, the richness in bacteria of the bile, which poses the risk of infections spreading to the peritoneal cavity.

Since in this position, the gallbladder is still very mobile.

The development of a ma tractus is very slow, thus upon removal of the drainage tube, the risk for an even larger bio leakage is big.

Transhepatic Approach

The trans hepatic approach to colo cystostomy is thought to minimize the risks of chemical and bacterial sitis.

According to this technique, the drainage is inserted through the abdominal wall and through the liver parenchyma to reach the gallbladder.

At this point, the tube is located in position and gentle traction is applied.

As you can see from this cartoon, this motion pulls the gallbladder to adhere to the liver surface, thus limiting the risk of bio leakage.

In disposition, gallbladder will be less mobile and the development of a major tractus will be quicker according to Adams and colleagues and major tractus could be obtained in as little as one week.

Since the normal treatment with percutaneous colostomy averages two weeks, this approach limits the risk of bi leakage upon removal of the drainage tube.

The only disadvantage of this approach is the increased risk of bleeding connected to puncture of the liver.

Once again, this risk is limited by appropriate patient selection.

Henceforth, we will only discuss drainage by trans hepatic approach.

Many radiologists use a combined ultrasound and fluoroscopic approach to establish a percutaneous success and advocated the use of g wires and cell techniques.

However, during the course of this lecture, we will demonstrate how the procedure can be safely and confidently performed without the need of a fluoroscopy or g wires is a purely ultrasound guided technique and with a one step catheter insertion.

Equipment Needed

Let's see what equipment is needed to perform in ultrasound guided per cystostomy, the procedure should be strictly sterile.

That's on the surgical table.

Should be prepared beforehand, swaps and disinfectant such as chlorine, sterile drapes, a sterile transducer cover with rubber bands to keep it in place.

Sterile ultrasound gel signs, s and needles, and the surgical lab blade for a skin incision.

The star of the whole procedure is the so-called pigtail catheter.

This is a catheter which features a removable rigid internal metallic lumen and a coil.

And there are several types of picture catheter from a number of manufacturers.

The most important feature is the locking wire, which locks the coil and prevents catheter dislodgement, as you can see from the movie.

And this particular catheter model as skater manufactured by angiotech.

By pulling the wire, the coil is firmly locked.

We customarily use a seven French catheter, but eight and nine French are similarly acceptable.

Performing the Procedure

Once all your equipment is prepared, it is time to set the stage for the procedure.

The patient will be laying supine on the operative table.

The upper right abdominal quadrant will be scrapped with disinfectant.

Remember that this is a procedure that can be safely performed at bedside.

Even in an intensive care environment, the steroid grapes should be placed in such a way to Del Limitate in operative field as as small as possible.

Some sterile ultrasound gel should be placed on the operative field.

The ultrasound probe should be clouded with a sterile cover.

Considering that the tube is to be inserted with a cranial co angle.

Those who are comfortable holding the ssus in the left hand and inserting the drainage with the right hand should be standing on the patient's left side and vice versa.

At this point, the anesthetic should be injected first in the skin and subcutaneous fatt.

Then in the masal layer and in the peral peroneum, this is best done.

Under ultrasound guidance, we ly inject 20 liters of Xi Tane.

Once the area is anes size, the two millimeter longer skin incision should be made at the incision site.

The pigtail catheter is now introduced through the incision and easily advanced through the subcutaneous.

Fat in insertion through the muscle layer requires a certain amount of force that this depends on the general condition and on the age of the patient.

At this point, it is useful to ask the patient to hold a breath in order to quickly and safely introduce the catheter through the liver and in one single and decid motion inside the gall bladder as shown, shown in this sequence.

As you see, this procedure does not require the use of guidewire inserted under fluoroscopic guidance and can be safely performed with a one step approach.

This movie shows how sometimes the gallbladder wall gives an elastic and persistent resistance to catheterization.

This resistance must be worn with the right amount of force taking care of not puncturing the opposite wall.

Once the catheter is in place and the metal stiffening cannula is removed by pulling the wire, the coil is locked as shown in this movie.

This ultrasound image shows how the catheter with the locket coil is gently pulled to allow the gallbladder to firmly adhere to the liver surface.

This will prevent by leakage through the insertion hole.

The bile can be aspirated by a signage or connected to a collecting bag.

Remember to always hold a gentle traction to minimize the mobility of the gallbladder.

After some minutes, the bile will be flowing through the catheter in the collecting bag as shown in this picture.

Complications

Any drainage procedure though minimally invasive, entails a certain risk of complications following percutaneous and trans hepatic insertion of a drainage tube in the gall bladder or a bleeding can occur in the abdominal wall or in the liver.

A good PAs selection based on the exclusion of patients with reduced coagulator function will minimize this risk.

As mentioned before, leakage of bile is a feared and extremely dangerous complication.

It can lead to chemical or infectious persis.

The trans hepatic approach by fixating the gallbladder against the liver surface reduces the risk of bio leakage.

Catheter dislodgement may have two possible negative effects.

On one hand, this dis larger catheter does not work and the CO is not decompressed.

On the other hand, the premier release dislodged catheter leaves a hole in the gall blood wall, which may lead to by leakage.

Finally, the development of a fistula as well as any infectious complication is always present.

Case Examples

Case 1: Suspected Bile Leakage

Sometimes a leakage from a gal bladder drainage is suspected.

The role of the radiologist and on the ultrasound specialist is to reveal or roll out the leakage, map it and if possible stop it.

A leakage is suspected every time a patient with a gallbladder drainage experiences a pain compatible with a peritoneal limitation.

In this particular case, the patient was in a coma, so a physical examination could not be performed and abdominal CT scan obtained it because of suspected intestinal paralysis revealed the presence of a paralytic fluid collection and it could not be exactly determined if the gallbladder drainage tube was correctly placed.

The radiologist on call was asked to rule out by leakage and catheter dislodgement.

The problem was solved by injecting a diluted ultrasound contrast agent through the drainage tube into the gallbladder.

As you can see in these images, because contrast agent fills the gallbladder here you can see some filling defects due to the presence of sludge and no leakage could be shown further.

Morrow with these images, it could be clearly established that the transa catheter was correctly positioned.

This examination was performed at bedside very quickly and with very little effort.

However, as it often happens, the referring physician asked for confirmation of the findings by fluoroscopy.

The fluoroscopic examination shows the correct position of the drainage tube and upon injection of iodinated contrast, agent by leakage was once again probably in a less elegant way, ruled out.

Case 2: Suspected Catheter Dislodgement

This is a different case in which dislodgement of the cystostomy tube was suspected because no bile was flowing through the atic tube.

Saline could be injected but not aspirated through the tube.

Once again, diluted contrast agent was injected through the tube and as you can see in the picture, the tube is clearly not anymore trans hepatic.

It lies in the peritoneal space between the abdominal wall and the liver.

By the way, this was a non lock pigtail catheter.

In order to minimize the risk of dislodgement, we always recommended session of locked catheters.

Case 3: Gallbladder Rupture

A question that is often raised is a for rupture of the gallbladder.

In a non-op operable patient should be treated by insertion of the drain tube in the gallbladder itself or in the peric cystic fluid collection associated to the rupture.

In my experience, this the gall bladder is still the standard.

An attempt should be made to decompress it.

Transapically in this particular patient and abdominal MR.

Scanner revealed the wall thickening of the gallbladder compatible with s indicated by the blue arrow and the is more cystic collection of fluid indicated by the radar arrow.

It was uncertain whether the collection of fluid represented that bile leaked from myo ruptured al bladder or simply inflammatory fluid.

The surgeon requested the ultrasound guided drainage of the gel bladder and asked the ultrasound specialist to determine whether there was a rupture or not.

After the ultrasound guided insertion of a drain tube in the gall blood, the diluted ultrasound contrast agent was injected through the tube, which revealed the correct positioning of the tube and the presence of a leakage from a ruptured free wall of the gall bladder as indicated by the red arrow.

The finding was comparable to the one previously seen by MR only.

This time ultrasound was more specific than MR in determining the cause of this fluid collection.

Summary

In summary, trans hepatic ultrasound guided drainage of the gallbladder.

There is a minimal invasive technique which can obtain a quick, safe, and effective decompression of the gallbladder.

Whether this procedure is intended is a breach to surgery or as a definitive treatment, the positioning of a locked coil pigtail catheter by trans hepatic approach minimizes the risk of a bio leakage.

A fewer the complication of cystostomy.

Well, this concludes our lecture on ultrasound guided, the drainage of the gall bladder.

I hope you enjoyed it and I wish you a nice day.