Seldinger versus Trocar technique for percutaneous cholecystostomy: impact of access route on procedural time and post-procedural pain

To compare procedural time (primary outcome) and technical success, clinical success, post-procedural pain and safety outcomes between the Seldinger and Trocar techniques for percutaneous cholecystostomy (PC) in high-risk patients with acute cholecystitis.

This retrospective cohort study included 169 consecutive patients (Seldinger: n = 130; Trocar: n = 39) who underwent ultrasound-guided PC between January 2020 and August 2024. The primary outcome was procedural time. Secondary outcomes were technical and clinical success, post-procedural pain (defined as the requirement for strong [WHO Step-3] opioid analgesics), adverse events graded per the Society of Interventional Radiology (SIR) Adverse Event Classification, and 30-day mortality. Multivariable regression with marginalization was used to estimate adjusted associations between technique and outcome, adjusting for disease severity (TG18 grade), comorbidities, gallbladder morphology, and anatomical approach (transhepatic vs. transperitoneal). Inverse-probability-of-treatment weighting and confounder-score adjustment were performed as sensitivity analyses.

The Trocar technique was significantly faster (median procedural time 81 s [IQR 69-99] vs. 246 s [IQR 199-399]; adjusted mean difference -212.78 s; 95% CI -314.68, - 110.88; p < 0.001). Both techniques achieved high technical (99.2% vs. 100%) and clinical success rates (98.5% vs. 94.9%). Overall opioid requirement did not differ between techniques (adjusted OR 1.01; p = 0.97). A significant interaction (effect modification) was observed between technique and access route: in the transperitoneal subgroup the Seldinger technique was associated with a 7-fold higher risk of severe pain than the Trocar technique (adjusted OR 7.36; 95% CI: 1.48, 36.65; p = 0.015), whereas no difference was found in the transhepatic subgroup. The 30-day crude mortality rate was higher in the Trocar group (23.1% vs. 6.2%); cause-specific adjudication suggested that the excess deaths were attributable to non-biliary sepsis and underlying comorbidities rather than procedure-related events, although residual selection bias toward use of the faster technique in unstable patients cannot be excluded.

The Trocar technique is a time-efficient alternative to the Seldinger technique for percutaneous cholecystostomy. Our findings suggest that, when transperitoneal access is anatomically unavoidable, the Trocar technique may be preferred to reduce procedural time and severe post-procedural pain. Confirmation in larger prospective studies is warranted.