Eric vanSonnenberg, MD •¿ Horacio B. D'Agostino, Alan Lurie, MD2 •¿ Robert R. Varney, MD

MD •¿ Giovanna Casola, MD •¿ David B. Hoyt, MD •¿

Gallbladder Perforation and Bile Leakage: Percutaneous [email protected] Three patients with spontaneous gallbladder perforation and one with an iatrogenic bile leak causing bile peritonitis were treated success fully by means of percutaneous catheter drainage. Three patients had cholelithiasis as the cause of perforation; the fourth patient had previously undergone gallstone dis solution with methyl terf-butyl ether lavage and developed bile peritonitis a few hours after remov al of the catheter. In three patients, a percutaneous cholecystostomy catheter provided successful decom pression; in the fourth patient, drainage was performed with a per cutaneous sump catheter in the sub hepatic space adjacent to the gall bladder. No specific complications occurred. Follow-up was performed at 1, 12, 22, and 59 months, respec tively. To date, one of the four pa tients has undergone elective chole cystectomy (1 month after drain age). The remainder of the patients are asymptomatic. This preliminary experience suggests that the severe complication of gallbladder perfora tion and bile leakage may be treat ed, at least temporarily, by means of percutaneous drainage. Index terms: Cholecystitis, 762.285 •¿ Callblad der, calculi, 762.289 •¿ Gallbladder, interven tional procedure, 762.129 •¿ Gallbladder, perfo ration, 762.285 Radiology

C

OMPLICATED medical illnesses and increasing age are factors that increase the frequency of mortal ity when cholecystectomy is per

formed for acute gallbladder disease. Several recent articles document treatment of acute calculous chole cystitis in high-risk patients by means of percutaneous cholecystos tomy (PC) (1—5).In this article, we

describe an expanded use of PC—for treatment of frank perforation of the gallbladder or leakage of infected bile. PC or catheter

drainage

permit

surgery

and general

anesthesia

in the

acute setting. PATIENTS

AND METHODS

Four patients (two men and two wom Three

patients

had an acute epi

sode of cholecystitis with septicemia due to gallstones. Each of these patients was considered high risk for surgery. Two pa tients were over 70 years old and had multiple

medical

problems

(previous

myocardia! infarction, renal failure, neu rovascular disorder); the third patient was dependent on a ventilator due to adult

respiratory distress syndome and pulmo nary emboli and had been in the inten sive care unit for over 1 month with multisystem organ failure. The fourth pa tient was 36 years old and had bile penito nitis, but was otherwise healthy. She had

refused cholecystectomy

for symptomatic

accordance with U.S. Food and Drug Ad

I From

the

CC.,

Departments

of

AL.,

Medicine

R.R.V.),

Radiology

(E.V.,

(E.V.),

and

Surgery (D.B.H.), University of California, San Diego, Medical Center, 225 Dickinson St. San Diego, CA 92103. Received June 25, 1990; revi sion requested August 14; revision received Oc tober 15; accepted November 12. Address re

print requests to E.V. 2 Current

address:

Diego, Calif. c RSNA,

1991

Alvarado

Hospital,

San

catheter (Medi-tech/Boston Scientific, Watertown, Mass), a 12-F sump catheter (Medi-tech), and one 8-F and one 10-F pigtail nephrostomy catheter (Cook, Bloo mington, md). Broad spectrum antibiotics

were administered

to each patient.

RESULTS Catheter drainage

enabled success

management

of the

acute perforation and leakage in each patient. The patients were treated with a combination of catheter drain age, antibiotics, and supportive mea sures until sepsis cleared tients were symptom-free. tient defervesced within

and leukocytosis

and the pa Each pa 48 hours,

resolved within 4

days in all patients.

All patients

sum

vived the acute episode, and all are alive at follow-up. Catheters me mained in the patients for 14, 19, 30, and 36 days, respectively.

The cathe

tens were removed when each patient was clinically well with respect to gallbladder infection and leakage (ie, sepsis resolved, condition at physical

examination improved, and bile drainage was clear). Cholecystogmams were obtained of two patients and me vealed patent cystic and bile ducts. Patients were followed-up at 1, 12,

22, and 59 months, respectively. Bile cultures were positive in all patients. Three patients had Escheri chia coli, one had entemococcus, one the hole in the gallbladder. All patients had Enterobactemiaceae, and one had werefebnile (101°—104.2°F [38°—39.7°C]), yeast (two patients had more than and had leukocytosis (white blood cell one organism). After the successful ministration-approved

H.B.A.,

with attempted

US-guided drainage was performed and supplemented with use of fluorosco py in three patients. CT was used for guidance in one patient. Drainage cathe ters included a 7-F locking gallbladder

ful nonoperative

en) aged 36—83 years are included in the study.

experience

percutaneous treatment of gallbladder perforation and peritonitis from bile leakage.

ted healing of four patients with a perforated gallbladder, obviating

gallstones and had undergone successful dissolution of multiple gallbladder calculi with methyl tert-butyl ether (MTBE) in

1991; 178:687-689

sent our entire

protocol.

She me

turned to the hospital 4 hours after ne moval of the PC catheter with symptoms and signs of acute bile peritonitis from

counts

were

10,600—18,400/mm3

[10.6-

18.4 X 109/LJ) with a left shift. Perfora tion was documented sound (US), computed

and/or

fluoroscopy.

by means of ultra tomography (CT),

These patients repre

Abbreviations:

MTBE methyl tert-butyl

ether, PC = percutaneous

cholecystostomy.

687

gallbladder drainage, treatment for the gallstones was as follows: obser vation in two patients, contact disso lution by means of MTBE in one pa tient (Fig 1), and cholecystectomy in

one patient (Fig 2). In the latter pa tient, cholecystectomy was per formed 1 month after catheter drain

age, and the gallbladder be partially gangrenous

was found to with granu

lomatous reaction microscopically; at the time of the elective surgery, the

patient was not acutely ill, and he was ambulatory and pain-free. The patient with the bile leak after MTBE dissolution had the second PC cathe tem removed without problem 19 days

after the acute bile leak. The patient

a.

b.

has remained asymptomatic. Chole cystectomy was discussed with and

recommended three

to all four patients;

of the four refused.

DISCUSSION The salient feature of these cases is that percutaneous drainage effective ly enabled the treatment of gallblad

der perforation and bile leakage with infection and allowed healing of the gallbladder. This method of therapy avoided cholecystectomy in the acute setting, and, to date, has obviated surgery in three of the four patients.

The drainage

may have been lifesav

ing in the two high-risk patients with multiple medical problems

whom mortality

is statistically

em than in healthier

patients

in

great who un

dergo elective cholecystectomy. While

elective

safe, morbidity rise markedly

cholecystectomy

and mortality in the elderly

with severe respiratory

is

mortality

with many controvem

rates

with

d. 1.

Images of a 52-year-old

woman,

cholecys

tostomy vary from 3.5% to over 20% (9,10), depending on the patient's physiologic state at the time of sum

and intubated,

with fever and sep

sis. (a) Transverse sonogram shows the lateral penicho!ecysticsubhepatic fluid collection (ar rows) due to gallbladder perforation. (b) Cholecystogram demonstrates the large, partially obstructing stone in the neck of the gallbladder (arrows); the gallbladder wall perforation exits laterally into the infected collection. (c) Cholecystogram obtained 12 days after PC shows that the perforation has healed. Obstruction from the stone is still present (arrows). Another stone is visualized in the midportion of the gallbladder (arrowheads). (d) Cholecys togram obtained 3 hours after administration of MTBE shows that the stones are dissolved and the cystic duct is patent.

patient

with acute cholecystitis

and a

life-threatening arrhythmia; howev em,catheter injection of contrast ma

and necrosis

previously

(12-

healing of the gallbladder

were effective in our patients. We

wall oc

curred with catheter decompression and antibiotics, despite proved perfo ration and bile leakage. Surgical principles suggest that perforation is

suggestive

of necrosis, and necrosis

fected cholecystitis

perforation.

has been considered an indication for emergency surgery. In one study, the authors suspected gallbladder perfo ration and used PC to cure an elderly

by perforation

have been reported

tenial did not confirm perforation (11). The most interesting pathophysio logic finding in our patients was that

requires emergent removal and de bnidement of tissue. The one patient who underwent cholecystectomy, 4

due to gallstones

plicated

14). As in the these clinical life-threatening percutaneous last resort. A

gery. Hydrops, empyema of the gall bladder, and calculous and acalculous cholecystitis of the gallbladder with out perforation have been drained ef fectively by means of percutaneous cholecystostomy (1—5).Perforated in

688•¿ Radiology

semicomatose

patient

compromise,

sies—mncluding indications for use, frequency of use, and advisability in relation to cholecystectomy. In addi tion,

Figure

rates

myocamdial disease, sepsis, and frank gallbladder perforation (6—8).Even cholecystostomy was considered to be a high risk in these patients; it is

an operation

c.

weeks after PC, had a partially gan gmenous gallbladder at surgery with a granulomatous reaction microscopi cally,

consistent

with

Clinically,

a contained

the patient

was asymptomatic. Successful percu taneous catheter drainage of con tained abscesses in the pancreas and gastrointestinal tract that were com

currently

patients in this series, situations are usually emergencies, and treatment is used as a variety of catheters

prefer

a locking

7-F pigtail

catheter. This catheter is easy to in sent and may be used for drainage or dissolution therapy (15). Follow-up has been expectant for two patients in our series. Neither has had recurrence of symptoms at 12 and 59 months. One of these patients continues to have gallstones; the oth em had

the

stones

dissolved

prior

to

the bile leak. A third patient under went gallstone dissolution with MTBE 3 weeks after PC. Follow-up cholecystograms of that patient docu mented closure of the perforation prior to solvent infusion. The patient

has been asymptomatic

with no stone March 1991

b.

a. Figure

2.

Gallbladder

infection

C.

“¿necessitates― as perforation

into the peritoneum

and overlying

soft tissues. (a) CT scan shows the gall

stones (arrowheads). (b) Percutaneous catheter placed through the overlying purulent collection into the gallbladder by using CT guidance. This route was chosen rather than the conventional transhepatic approach to enable the additional drainage of the soft-tissue abscess. (c) Af ter removal

of 75 cm3 of pus, the gallbladder

and overlying

soft tissues are decompressed.

The acute episode

subsided,

and the patient

un

derwent elective cholecystectomy 1 month later.

recurrence for almost 2 years. The fourth patient underwent an elective

Acknowledgments: Our appreciation to Mi chae! Bauman, RT, and Peggy Chambers.

cholecystectomy.

In this small series, percutaneous treatment was a potentially lifesav ing option for patients with gallblad der perforation. In cases of perfoma tion, PC allows decompression of bile and prevents continued leakage, while allowing the perforation to seal. This suggests that catheter drainage can be used to treat bile peritonitis from gallbladder leakage in the acute setting. Failure of symp toms and signs of sepsis and pemitoni tis to resolve

implies

failure

are needed

1.

2.

to determine

3.

4.

5.

how

broad the applicability of this treat ment is, whether the benefits are temporary, and if PC may be used as a definitive front-line therapy in se lected patients. U

6.

7.

8.

Volume 178 •¿ Number 3

McGahan P, Lindfors KK. Percutaneous cholecystostomy: an alternative to surgical cholecystostomy for acute cholecystitis? Radiology 1989; 172:481-486. Lohela P, Soiva M, Suramo I, Taavitsainen

M, Holopainen 0. Ultrasonic guidance

of pemcu

taneous therapy and indicates the need for emergency surgery. Further studies

References

for percutaneous puncture and drainage in acute cho!ecystitis. Acta Radio! [Diagn] 1986; 27:543—546. Shaver RW, Hawkins IF Jr. Soong J. Per cutaneous cholecystostomy. AJR 1982; 138:1133—1136. vanSonnenberg E, Wittich CR, Casola C, et a!. Diagnostic and therapeutic percuta neous gallbladder procedures. Radiology 1986; 160:23-26. Vogelzang RL, Nemcek AA Jr. Percuta neous cholecystostomy: diagnostic and therapeutic efficacy. Radiology 1988; 168:29-34. Alexander 5, McA!pine FS. Cholecystec tomy in the cardiac patient. Med Clin North Am 1966; 50:495-500. Glenn F, Wantz C. Acute cholecystitis following the surgical treatment of unre lated disease. Surg Gynecol Obstet 1956; 102:145-153. !bach JR. Hume HA, Erb WH. Cholecys tectomy in the aged. Surg Gynecol Obstet 1968; 126:523-528.

9.

Welch JP, Malt RA. Outcome of cholecys tostomy. Surg Gynecol Obstet 1972; 135:717-720. 10. Glenn F. Cholecystostomy in the high risk patient with biliary tract disease. Ann Surg 1977;185:185—191. 11. Longmaid HE III, Bassett JC, Cottlieb H. Management of gallbladder perforation by percutaneous cholecystostomy. Crit Care Med 1985; 13:686-687. 12. Steiner E, Mueller PR, Hahn PF, et a!. Complicated pancreatic abscesses: prob lems in interventiona! management. Radi ology 1988; 167:443-445. 13. vanSonnenberg E, Wittich CR, Casola C, et a!. Complicated pancreatic inflamma tory disease: diagnostic and therapeutic role of interventiona! radiology. Radiolo gy 1985; 155:335—340. 14. Neff CC, Lawson DW. Boerhaave syn drome: interventional radiologic manage ment. AJR 1985; 145:819—821. 15. vanSonnenberg E, D'Agostino, HB, Casola

C, Varney RR, Ainge GD. Interventiona! radiology in the gallbladder: diagnosis, drainage, dissolution, and management stones. Radiology 1990; 174:1-6.

of

Radiolocrv •¿ 689

Gallbladder perforation and bile leakage: percutaneous treatment.

Three patients with spontaneous gallbladder perforation and one with an iatrogenic bile leak causing bile peritonitis were treated successfully by mea...
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