|Year : 2022 | Volume
| Issue : 2 | Page : 39-41
Creative resource utilization in rural settings: The urinary catheter as a cholecystostomy tube
Taha Mollah1, Shanthapriya Tellambura2
1 Department of General Surgery, Swan Hill District Health, Swan Hill; Department of General Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
2 Department of General Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
|Date of Submission||07-Feb-2022|
|Date of Decision||07-Apr-2022|
|Date of Acceptance||22-Apr-2022|
|Date of Web Publication||07-Jul-2022|
Department of General Surgery, Swan Hill District Health, 48 Splatt Street, Swan Hill 3585, Victoria
Source of Support: None, Conflict of Interest: None
Cholecystostomy tubes are an established treatment option for patients with acute cholecystitis who are considered high risk for cholecystectomy. This is typically done as an interventional radiology procedure through a pigtail catheter inserted percutaneously. A 63-year-old diabetic male presented to our remote Emergency Department in rural North-Western Victoria (Modified Monash Model 4), with severe, stabbing epigastric pain. Despite normal bloods and imaging, the patient became progressively unwell necessitating a diagnostic laparoscopy and open conversion, which revealed acute acalculous gangrenous cholecystitis. A cholecystectomy was attempted and subsequently abandoned as safe dissection within Calot's triangle, without damaging biliary structures, was not possible. Based on the limited available resources at our rural center, a urinary (Foley) catheter was placed in the gallbladder and Hartmann's pouch sutured around it to act as a temporizng cholecystostomy tube while awaiting transfer to a tertiary center. The Foley catheter was removed after 6 weeks with no further intervention required with the patient making a full recovery. Compared to patients in urban areas, rural residents are more likely to experience health-care disadvantages, including increased likelihood to undergo procedures by specialists operating outside of their scope of practice and higher rates of emergency-related intensive care unit admissions. Despite this, and regardless of acuity, specialist availability, or resource distribution, patients will continue to present to rural services with serious medical issues. In such situations and in resource-poor settings, creative solutions are required to temporize ill patients, as we have reported, and represent an important facet of care in a rural setting.
Keywords: Cholecystostomy, resources, rural
|How to cite this article:|
Mollah T, Tellambura S. Creative resource utilization in rural settings: The urinary catheter as a cholecystostomy tube. J Surg Spec Rural Pract 2022;3:39-41
|How to cite this URL:|
Mollah T, Tellambura S. Creative resource utilization in rural settings: The urinary catheter as a cholecystostomy tube. J Surg Spec Rural Pract [serial online] 2022 [cited 2022 Dec 3];3:39-41. Available from: http://www.jssrp.org/text.asp?2022/3/2/39/350161
| Introduction|| |
Cholecystostomy tubes are an established treatment option for patients considered high risk for cholecystectomy. It involves placement of a tube, typically a radiopaque polyethylene pigtail catheter, directly into the gallbladder to allow for drainage as an interventional radiology procedure. Such catheters or services are not available at all centers, however, including in several rural centers, and in such cases, creative solutions need to be sought. Foley urinary catheters come in a variety of forms but typically utilize silicone or coated natural latex and can be left in situ for up to 6 weeks and theoretically have the same functional outcome as a pigtail catheter for cholecystostomy.
Cholecystostomy is not without complications, however, with a 15.4% mortality rate in patients treated with cholecystostomy compared to 4.5% in those treated with acute cholecystectomy. Early laparoscopic cholecystectomy is the recommended treatment for patients with acute cholecystitis but may not always be feasible.
| Case Report|| |
Our rural town is located in North-Western Victoria, Australia, with a population of 10,905 (Modified Monash Model classification 4). The closest tertiary hospital with specialist care availability is approximately 4 h by road 338 km away in Melbourne, with our hospital staffed by visiting medical officers only.
A 63-year-old male presented to our emergency department (ED) with severe, stabbing epigastric pain, his second visit to the ED with these symptoms over the course of a week. On both occasions, the patient was worked up for chest pain and discharged on first presentation once cardiac workup returned as normal.
During the patient's second presentation, a surgical consultation was sought due to complaints of abdominal pain. Laboratory investigations revealed a leukocytosis with a white cell count (WCC) of 15 (reference range 4–12 × 109/L) but normal C-reactive protein (CRP) of 2 (reference range <5.0 mg/L) and normal liver function tests. A computed tomography (CT) scan of the abdomen and pelvis as well as two subsequent abdominal ultrasounds (US) were sought which revealed a distended, but normal-appearing gallbladder with no other explanation for the patient's symptoms. The patient was commenced on broad spectrum antibiotics with intravenous Piperacillin-Tazobactam (Tazocin®) 4 g/0.5 g tds for presumed abdominal sepsis and managed conservatively.
During this period, the patient developed several febrile spikes with a temperature of 39.0°C, worsening abdominal pain, and CRP increasing to 150 and WCC to 20. The patient was emergently transferred to theater for a diagnostic laparoscopy (eventually necessitating open conversion) which revealed a necrotic, perforated gallbladder consistent with a diagnosis of acute acalculous gangrenous cholecystitis. A subtotal cholecystectomy was performed but due to severe adhesions and edema preventing safe dissection, as well as limited critical care availability and resource access at our center, a complete cholecystectomy was abandoned. To prevent bile leak or damage to biliary anatomy, a urinary (Foley) catheter was inserted and inflated in the gallbladder and Hartmann's pouch sutured around it [Figure 1]. This would act as a temporizing cholecystostomy tube while the patient transferred to a tertiary center for definitive management. In joint discussion with the referral center, a decision was made to keep the cholecystostomy tube in situ for 6 weeks. Post removal of the Foley catheter, the patient continued on to make a full recovery and did not require further intervention.
|Figure 1: Computed tomography cholangiogram - demonstrating placement of Foley catheter in Hartmann's pouch and opacification of biliary tree with retraction of the gallbladder around the catheter|
Click here to view
| Discussion|| |
In our case, cholecystectomy was deemed unsafe without specialist hepatobiliary input and therefore drainage of the gallbladder with cholecystostomy was preferred. Acalculous cholecystitis is often hard to diagnose with lower sensitivity and specificity on CT and US compared to calculous cholecystitis and typically presents in critically ill patients. Cholecystostomy can be used as a definitive option in most cases but is still associated with a high mortality approaching 15%.
This out of the box thinking underpins the challenges facing rural patients and practitioners. Access to healthcare continues to be the most important rural health-care priority as identified in the Rural Healthy People 2020 survey. Regardless of acuity, specialist availability, or resource distribution, patients will continue to present to rural services with serious medical issues. Despite similar postoperative outcomes for rural laparoscopic surgery compared to metropolitan centers, rural residents are still more likely to experience health-care disadvantage; this includes increased likelihood to undergo procedures by specialists operating outside of their scope of practice and higher rates of emergency-related intensive care unit admissions. Despite this, rural and remote services have continued to adapt in order to temporize patients and provide an excellent level of care. Notable examples of temporization in the rural setting include the use of the Sengstaken-Blakemore tubes for rapid upper gastrointestinal bleeds, temporary ligations of severe arterial lacerations, Bakri balloons for life-threatening postpartum hemorrhage, and lateral canthotomy for orbital compartment syndromes. While these procedures are well established, we contend that the use of a Foley catheter as a cholecystostomy tube is a novel example and represents a creative solution where traditional equipment or specialization was not available.
With access to higher levels of resources, research has shown no difference in postoperative outcomes for patients in rural versus nonrural hospitals. This requires legislative level intervention to ensure equitable distribution of resources and care in the rural setting. Otherwise, creative solutions will continue to be required.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
We would like to thank our patient for consenting in allowing us to write this case report.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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