Treatment of acute suppurative cholecystitis with coagulopathy by percutaneous transhepatic gallbladder drainage after hepatic needle-track ablation: report of a new technique

Acute suppurative cholecystitis (ASC) is a common acute abdominal disorder in clinical practice, most often in older women, and the pathogenesis underlying 90% of cases is obstruction of the cystic duct by gallstones (1). The incidence of gallbladder calculi increases with age, and many patients with ASC will also have diseases of the circulatory and respiratory systems, diabetes, and poor kidney function. Moreover, a systemic infection caused by ASC can aggravate these complications, making it difficult to control the infection with conservative treatment only. However, emergency surgery in such patients with comorbidities may lead to a higher incidence of complications and mortality. In 1980, Radder first reported successful drainage of a gallbladder empyema accumulation by ultrasound-guided percutaneous cholecystostomy (2). Clinical studies have confirmed that percutaneous transhepatic gallbladder drainage (PTGD) is a safe and effective treatment for highrisk ASC (3). Gallbladder drainage and decompression can reduce the symptoms of poisoning and improve liver function and systemic condition, gaining time to manage severe medical diseases, allowing the patient to recover from a critical illness safely, and then undergoing laparoscopic cholecystectomy (LC) at a later date. However, PTGD can significantly increase the risk of surgical bleeding in critically ill patients with a coagulopathy. Anderloni et al. (4) reported using for the first time a recently developed lumenapposing, fully-covered, self-expanding metal stent mounted on an electrocautery-enhanced delivery system to perform emergency endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) in 4 prohibitively high-risk surgical patients with ASC. The patients had a prolonged INR and/or were taking anticoagulants. Unfortunately, 2 of the treated patients died 2 and 3 days after the procedure due to multiorgan failure, but without any signs of bleeding. We report the successful management of a case of PTGD after hepatic needle-track ablation, which will expand the surgical indications for PTGD, avoid emergency surgery, and facilitate subsequent, non-urgent LC.