In this video we will show gallbladder drainage in a 44 year old man with widely metastatic appendiceal carcinoma but good functional status, who had bilatereal nephrostomy tubes. He presented with RUQ pain, tenderness, normal LFTs, but CT and ultrasound showing a distended gallbladder with sludge, thus clear evidence of cholecystitis. He was felt to be a poor surgical candidate because of extensive carcinomatosis, and thus was considered for endoscopic gallbladder drainage.
At ERCP, the first task was biliary access. Since we were planning on placing a large caliber biliary stent, and pancreas was first accessed with a guidewire, we left the wire in the pancreatic duct during biliary access. A biliary sphincterotomy was performed, and a 4F 9cm soft material pancreatic stent placed. Next was the task of obtaining deep gallbladder access with a wire. We used a swing-tip catheter which is unique in that it bends up and down, allowing selective tip deflection within the bile duct. At first, the glidewire is bouncing off the valves in the cystic duct. Much like a fish swimming up a fish ladder, we are going to “swim” the catheter tip up the tortuous cystic duct by opening and closing the catheter handle. The catheter and wire work their way up into the fundus. The swing-tip is again useful once inside the fundus of the gallbladder. Notice all the stones and debris in the gallbladder. Once the wire is placed all the way to the end of the gallbladder, we dilated the cystic duct very carefully.
Then the gallbladder stent is inserted. It is a 20cm soft-material multi-sidehole stent developed as a “wedge” stent for pancreatic applications, developed by Fred Johlin MD of the University of Iowa for pancreatic applications. It is also a terrific stent for hilar and gallbladder drainage. Once the stent is in place, the gallbladder can be flushed by removing the guidewire from the Oasis introducer, and flushing and aspirating 100-200cc of sterile saline. The final fluoroscopy shows the nice positioning of this stent. In fact the patient did very well, surviving more than 6 months with this stent in place, until hilar biliary obstruction occurred- at that time bilateral metallic stents were placed and a new plastic stent replaced in the now collapsed and empty gallbladder.
Mutignani M, Iacopini F, Perri V, Familiari P, Tringali A, Spada C, Ingrosso M, Costamagna G. Endoscopic gallbladder drainage for acute cholecystitis: technical and clinical results. Endoscopy. 2009 Jun;41(6):539-46. Epub 2009 Jun 16.
Itoi T, Sofuni A, Itokawa F, Tsuchiya T, Kurihara T, Ishii K, Tsuji S, Ikeuchi N, Tsukamoto S, Takeuchi M, Kawai T, Moriyasu F.Endoscopic transpapillary gallbladder drainage in patients with acute cholecystitis in whom percutaneous transhepatic approach is contraindicated or anatomically impossible (with video). Gastrointest Endosc. 2008 Sep;68(3):455-60. Epub 2008 Jun 17.
Martin L. Freeman, M.D., University of Minnesota
Mustafa Tiewala, MD, University of Minnesota