Proper Use of Cholecystostomy Tubes

Abstract

Cholecystostomy tubes have traditionally been considered for the treatment of acute cholecystitis (calculous or acalculous) when definitive treatment (cholecystectomy) is contraindicated secondary to high morbidity or mortality risk. This risk can be related to the severity of the underlying gallbladder pathology and/or comorbid conditions with decompensation. The Tokyo guidelines for the management of acute cholecystitis, recommend cholecystostomy tubes in two specific situations; however, the data from multiple US reports indicate that current practice patterns are not adherent to the Tokyo guidelines, with only a minority of patients requiring cholecystostomy tube placement. Although the Tokyo guidelines were revised in 2018 (TG18), and now factor in patient comorbidities and physiologic status, controversy still exists regarding the indications for placement of cholecystostomy tubes. Once placed, the recommended management of cholecystostomy tubes based on TG18 is cholecystectomy within 3 months of initial tube placement. Cholecystectomy following cholecystostomy tube placement occurs rarely despite TG18 guidelines, leading to multiple tube-related complications and recurrent gallbladder pathology. Recommendations for management after cholecystostomy tube placement are not standard and primarily focus on the patency of the cystic duct and the patient’s surgical risk. Clear indications for the use of cholecystostomy tubes and their subsequent management are imperative. This chapter reviews the current literature on cholecystostomy tube placement and provides recommendations based on the best current evidence.