Controversies in transhepatic versus transperitoneal access for percutaneous cholecystostomy

Percutaneous cholecystostomy is a valuable intervention for managing acute cholecystitis in high-risk surgical patients.¹ Yet, the choice between transhepatic and transperitoneal access routes remains a topic of ongoing debate. Here, Nikolaos- Achilleas Arkoudis and Stavros Spiliopoulos (both Athens, Greece) analyse contemporary viewpoints to provide consensus on the best treatment pathway.

The transperitoneal approach accesses the gallbladder directly without liver transgression, making it preferable for patients with liver disease or bleeding disorders. Still, because it lacks the protective effect of liver tamponade, it is considered to carry a higher risk of bile leakage, which can cause peritonitis.² In contrast, the transhepatic approach has been traditionally reflected as a most popular route due to a lower chance of bile leakage, improved safety in cases where interposed tissues or fluid (ascites) are present, better catheter stability, and faster tract formation. However, due to the necessity of passing through the liver to reach the gallbladder, it is considered a higher risk of bleeding.²

Notably, recent studies show that the transperitoneal approach performs just as well as, if not better than the transhepatic approach. Particularly, studies by Michael D Beland et al and Joseph R Kallini et al demonstrated no statistically significant differences in the complication rates among the transperitoneal and transhepatic routes, while the Multicentre Audit of Cholecystostomy and Further Interventions (MACAFI) retrospective evaluation of 913 patients found that the transperitoneal route had a lower haemorrhagic complication incidence, fewer episodes of acute cholecystitis recurrences and fewer hospital re-admissions.^3,4,5

Nonetheless, neither route should be considered inherently superior in all scenarios, as no single option is the best option for all cases. It is critical to understand that procedural nuance matters, and that individualised decision-making based on technique (trocar or Seldinger), anatomy, and operator experience should be considered. Every patient’s status and clinical scenario is different; therefore, it would make sense that every procedure should be tailored to the specific circumstances. We should integrate anatomy, urgency, co-morbidities and operator tools, and prioritise according to what makes the procedure easier for the physician and safer for the patient. For example, a transperitoneal trocar approach may be optimal when the gallbladder is well-distended with a clear direct path, minimising risks of bile spillage.6 Conversely, a transhepatic Seldinger approach may offer greater safety if the gallbladder is not adequately distended. Similarly, the transperitoneal Seldinger approach should be avoided due to the potential of bile spills, and the transhepatic trocar approach should be avoided due to the large bore of the catheter transgressing the liver.⁶

After all, despite earlier assumptions, recent trials have shown that the trocar and Seldinger techniques are equally safe and effective; therefore, as equally acceptable techniques, they may also subsequently affect route choice.^7,8 Additional variables, such as expected catheter dwell time and plans for interval cholecystectomy, may all enter the equation.

Building on this controversy, recent consensus studies have reached differing conclusions, underscoring the complexity of the issue. One Delphi study recommended transhepatic access (83.4% agreement), while another suggested that both transhepatic and transperitoneal approaches are equally valid (80% agreement).^9,10 These studies evaluated several statements regarding the management of high-risk patients with acute cholecystitis and were mostly represented by non-interventional radiology physicians.

The lack of a one-size-fits-all solution highlights the need for interventional radiologists to lead this conversation and provide guidelines for the different scenarios. As they are the specialists most familiar with the technical intricacies of percutaneous cholecystostomy, they are best positioned to guide evidence-based decisions regarding the technical aspects of the procedure, while the rest of the issues regarding patient management can encompass the necessary multidisciplinary input.

Until such consensus studies are led by the interventional radiology community, flexibility and clinical judgment must prevail, and percutaneous cholecystostomy access route selection should remain tailored to each patient’s anatomy, clinical condition and the operator’s preferred technique.

References

1. M. Yokoe et al., “Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos),” J Hepatobiliary Pancreat Sci, vol. 25, no. 1, pp. 41–54, Jan. 2018, doi: 10.1002/jhbp.515.
2. N.-A. Arkoudis et al., “Percutaneous cholecystostomy: techniques and applications,” Abd Rad, Jun. 2023, doi: 10.1007/s00261-023-03982-2.
3. M. D. Beland, L. Patel, S. H. Ahn et al., “Image- Guided Cholecystostomy Tube Placement: Short-and Long-Term Outcomes of Transhepatic Versus Transperitoneal Placement.,” AJR Am J Roentgenol, vol. 212, no. 1, pp. 201–204, Jan. 2019, doi: 10.2214/ AJR.18.19669.
4. J. R. Kallini, D. C. Patel, N. Linaval, et al., “Comparing clinical outcomes of image-guided percutaneous transperitoneal and transhepatic cholecystostomy for acute cholecystitis,” Acta radiol, vol. 62, no. 9, pp. 1142–1147, Sep. 2021, doi: 10.1177/0284185120959829.
5. P. E. Jenkins, A. MacCormick, J. Zhong et al., “Transhepatic or transperitoneal technique for cholecystostomy: results of the multicentre retrospective audit of cholecystostomy and further interventions (MACAFI),” Br J Radiol, Jan. 2023, doi: 10.1259/bjr.20220279.
6. N.-A. Arkoudis, O. Moschovaki-Zeiger, and S. Spiliopoulos et al., “Transhepatic versus Transperitoneal Access for Percutaneous Cholecystostomy Remains Controversial: Interventional Radiologists Must Lead the Discussion,” Cardiovasc Intervent Radiol, May 2025, doi: 10.1007/s00270-025-04046-2.
7. L. Reppas et al., “Two-Center Prospective Comparison of the Trocar and Seldinger Techniques for Percutaneous Cholecystostomy,” AJR Am J Roentgenol, vol. 214, no. 1, pp. 206–212, Jan. 2020, doi: 10.2214/AJR.19.21685.
8. N.-A. Arkoudis et al., “US-guided trocar versus Seldinger technique for percutaneous cholecystostomy (TROSELC II trial).,” Abdom Radiol (NY), Apr. 2023, doi: 10.1007/s00261-023-03916-y.
9. J. M. Ramia et al., “International Delphi consensus on the management of percutaneous choleystostomy in acute cholecystitis (E-AHPBA, ANS, WSES societies),” Wor J of Emer Surg, vol. 19, no. 1, p. 32, Oct. 2024, doi: 10.1186/s13017-024-00561-8. N.-A. Arkoudis et al., “US-guided trocar versus Seldinger technique for percutaneous cholecystostomy (TROSELC II trial).,” Abdom Radiol (NY), Apr. 2023, doi: 10.1007/s00261-023-03916-y.
10. A. Pesce et al., “Management of high-surgical risk patients with acute cholecystitis following percutaneous cholecystostomy. results of an international Delphi consensus study,” Int J of Surg, Mar. 2025, doi: 10.1097/JS9.0000000000002325.

Nikolaos-Achilleas Arkoudis is a consultant radiologist and Stavros Spiliopoulos is a professor of interventional radiology at the Attikon University General Hospital, National and Kapodistrian University of Athens, Athens, Greece.