Percutaneous insertion of a cystic duct stent after cholecystostomy for acute calculous cholecystitis

Evidence-based recommendations on percutaneous insertion of a cystic duct stent after cholecystostomy for acute calculous cholecystitis. This involves inserting a tube called a stent into or across the cystic duct. The aim is to allow bile to flow through the tube, bypassing the blockage and preventing further obstruction.

# Recommendations
Evidence on the safety and efficacy of percutaneous insertion of a cystic duct stent after cholecystostomy for acute calculous cholecystitis is inadequate in quality and quantity. But because patients would otherwise need permanent external drainage, the procedure can be considered for this condition, as long as special arrangements for clinical governance, consent, and audit or research are in place. Find out what special arrangements mean on the NICE interventional procedures guidance page.
Clinicians wanting to do percutaneous insertion of a cystic duct stent after cholecystostomy for acute calculous cholecystitis should:
Inform the clinical governance leads in their healthcare organisation.
Give patients (and their families and carers as appropriate) clear written information to support shared decision making, including NICE's information for the public.
Ensure that patients (and their families and carers as appropriate) understand the procedure's safety and efficacy, and any uncertainties about these.
Audit and review clinical outcomes of all patients having the procedure. The main efficacy and safety outcomes identified in this guidance can be entered into NICE's interventional procedure outcomes audit tool (for use at local discretion).
Discuss the outcomes of the procedure during their annual appraisal to reflect, learn and improve.
Healthcare organisations should:
Ensure systems are in place that support clinicians to collect and report data on outcomes and safety for every patient having this procedure.
Regularly review data on outcomes and safety for this procedure.
Patient selection should be done by a multidisciplinary team.
This procedure should only be done in specialist centres by clinicians with specific training and experience in this procedure.
Further research should report details of patient selection, the procedure undertaken, the type of stent used and whether the patient is later able to have definitive surgery.# The condition, current treatments and procedure

# The condition
Acute calculous cholecystitis is inflammation of the gallbladder caused by a gallstone or biliary sludge that blocks the cystic duct. The blockage in the cystic duct causes bile to build up in the gallbladder, increasing the pressure inside it and causing it to become inflamed. Symptoms include pain, fever, nausea and vomiting.

# Current treatments
Treatments include intravenous fluids, medicines (analgesics and antibiotics), endoscopic or percutaneous biliary drainage, and surgery (laparoscopic or open cholecystectomy). NICE's guideline on gallstone disease recommends offering early laparoscopic cholecystectomy (to be carried out within 1 week of diagnosis) to patients with acute cholecystitis.

# The procedure
This procedure places a stent via a cholecystostomy tract into the cystic duct to provide antegrade gallbladder drainage and prevent further obstructive episodes of cholecystitis. This procedure is suitable for patients who otherwise need long-term external drainage.
Before the procedure, a percutaneous cholecystostomy and drainage is done to resolve the acute episode. This procedure is usually done using conscious sedation. The cholecystostomy drain is used for cholangiography to confirm cystic duct obstruction. Under fluoroscopic guidance, a guidewire and catheter are passed through the cholecystostomy tract, through the cystic duct and into the duodenum. A stent is then inserted and placed in or across the cystic duct.
After the procedure, an external gallbladder drain is usually left in situ for a few days to ensure that there is good antegrade drainage of bile into the duodenum. The external drain can then be removed after a satisfactory cholangiogram.