Transcholecystic approach for distal common bile duct stricture in a non-dilated biliary system: an alternative route

Abstract

A 63-year-old patient was admitted to intensive treatment unit with biliary sepsis due to a small distal common bile duct stone. Endoscopic retrograde cholangiopancreatography was initially attempted for insertion of a biliary stent but failed due to the presence of a periampullary diverticulum. Referral to interventional radiology for percutaneous drainage was considered the next alternative even though there was no dilatation of intrahepatic ducts. Due to complete absence of intrahepatic duct dilatation, the traditional percutaneous transhepatic route was considered rather challenging. An alternative percutaneous approach via the gallbladder and subsequent catheterisation of the duodenum via the distal common bile duct was successfully performed instead without complication. We would like to describe this technique as an alternative option for drainage of the non-dilated biliary system in patients with sepsis.

Background

Biliary obstruction is a result of stenosis or blockage of the bile ducts resulting in lack of bile drainage towards the duodenum. The aetiology may either be benign or malignant, and patients may present with right upper quadrant pain, jaundice, pruritus, weight loss or sepsis. Migration of gallstones to the distal common bile duct (CBD) is the most common cause of biliary obstruction, with a prevalence between 5% and 25%.¹

Direct access to the gallbladder is typically performed for percutaneous cholecystostomy, offering minimal invasive drainage of the gall bladder for high-risk patients with acute cholecystitis.^1–3 Percutaneous cholecystostomy is a technically straightforward procedure and mainly consists of obtaining ultrasound-guided access to the dilated gall bladder and then advancing a drain catheter over a guidewire.^{4 5} Catheterisation of the distal common bile and the duodenum via a transcystic route is slightly more technically demanding as manipulation of the guidewire via the cystic duct is required; the technique has previously been described as an alternative drainage option for patients with diffuse metastatic lesions and limited access via the liver parenchyma.⁶ We would like to describe this technique as an alternative option for a patient with sepsis with lack of dilatation of the biliary tree.

Case presentation and investigations

A previously fit and well 63-year-old man presented with a 1-day history of right upper quadrant pain, vomiting, loose stools and reduced appetite. Ultrasound demonstrated distended gall bladder and only a minor amount of pericholecystic fluid without any other evidence of acute cholecystitis (figure 1A). Symptoms were attributed to acute cholangitis, and treatment with antibiotics and fluids was commenced. Subsequent CT confirmed a partially obstructing 7 mm calculus in the distal CBD but no intrahepatic duct dilatation. The patient deteriorated further in the next 24 hours with advanced sepsis and had to be transferred to intensive care unit due to septic shock and respiratory failure. He was subsequently intubated for endoscopic retrograde cholangiopancreatography (ERCP), aiming to decompress the biliary obstruction. Unfortunately, ERCP failed to access the biliary tree due to the presence of a periampullary diverticulum (figure 1B). After further discussion among the multidisciplinary team of upper gastrointestinal surgery, intensive care and interventional radiology, percutaneous biliary drainage was considered the next alternative.

Figure 1.

(A) Ultrasound scan demonstrating a distended gallbladder and excluding acute cholecystitis. No dilatation of the intrahepatic bile ducts is detected. (B) Axial portal venous phase-contrast CT demonstrated distended gallbladder (GB), a degree of dilatation of the common bile duct (CBD) and the pancreatic duct (Pd), and the presence of a periampullary diverticulum (Div) situated anteriorly to the duodenum (D). Pancreatic calcification due to chronic pancreatitis is also noted. No mass lesion is detected. R, right.

Treatment

Preoperative

Preprocedural planning included evaluation of blood tests, ensuring adequate haemoglobin, platelets and coagulation function. Prior cross-sectional imaging and ultrasound images were reviewed. Written informed consent was obtained and the WHO checklist was completed. The procedure was performed under strict aseptic technique and with support from the anaesthetic team. Appropriate premedication, including prophylactic antibiotics, sedation and local anaesthetic, was administered.

Procedure

Local anaesthesia with 10 mL of 1% lignocaine was administered in the area of the skin around the gallbladder. Two gastropexy sutures with a distance of approximately 1 cm were advanced under ultrasound guidance in the gallbladder fundus to secure the gallbladder to the abdominal wall (figure 2A). Access between the two sutures was obtained with a 22 G introducer system (AccuStick, Boston Scientific), through which a 0.018″ wire was advanced in the gall bladder. When the coaxial system was advanced in the gallbladder, a 0.035″ wire was used and a 6 French BRITE TIP sheath (BRITE TIP, Cordis) was then inserted. Contrast injection confirmed the position of the sheath, the location of the cystic duct and the level of the obstruction (figure 3A). A hydrophilic 4 Fr C2 catheter (Glidecath, Terumo) and a hydrophilic 0.035″ wire (Glidewire, Terumo) were manipulated via the sheath to catheterise the duodenum. Once the stricture was crossed, contrast injection confirmed the position within the duodenum (figure 3B). Over a stiff wire (Amplatz Super Stiff, Boston Scientific), a 25 cm, 8.5 Fr biliary drain catheter (Cook) was inserted with a pigtail tip in the duodenum (figure 4A). The drain was secured, with advice of a cholangiogram within 4–6 weeks in view of the removal and with instructions not to remove the catheter before the next management step is defined.

Figure 2.

(A) Fluoroscopic image confirming percutaneous access between the two gastropexy sutures. The access wire is curved within the gallbladder (white arrow). (B) Schematic representation of the fluoroscopic picture (A). (C) Schematic representation of the difficulties in transcholecystic access in case gastropexy sutures are not used.

Figure 3.

(A) Cholangiogram via the access catheter delineates tortuosity of the cystic duct and the distal CBD tight stenosis (thick white arrow). Note that opacification of the pancreatic duct also occurs (thin white arrow). (B) Recanalisation of the tortuous cystic duct and catheterisation of the duodenum (thick white arrow) via the stricture of the distal CBD. CBD, common bile duct.

Figure 4.

(A) Cholangiogram via the external drain the day after the procedure confirming the drain in good position and opacification of the duodenum (thick white arrow). Note the presence of a nasogastric tube (thin white arrow). (B) Follow-up outpatient tubogram confirms patency of the cystic and common bile duct, with contrast flowing into the duodenum with no obstruction. Contrast is also visualised in the right hepatic duct. Note the two radiopaque gastropexy sutures running either side of the drain insertion (thick white arrow).

Outcome and follow-up

This procedure was done due to the high risk of undergoing surgery, and the drain was left in situ until the patient’s septic shock had resolved. After insertion of the biliary drain, the patient recovered well from sepsis and was discharged the following week.

Outpatient follow-up fluoroscopic study 6 weeks later with diluted water-soluble contrast administered via the external biliary drain demonstrated patent cystic and common bile duct and no filling defects indicating distal stone migration (figure 4B). Contrast was visualised in the duodenum. Proximal drain migration occurred, but this did not raise any concern. The patient was completely well. Subsequent elective cholecystectomy was planned in the immediate future.

Discussion

Access to a non-dilated biliary tree may be challenging due to the risk of multiple punctures and bleeding. Particularly for patients with sepsis, multiple attempts to obtain access to a non-dilated biliary system may worsen sepsis. Access via the gallbladder is much more simple from a technical perspective via both the transhepatic and the direct transcholecystic route. It has been sporadically described in the literature as an alternative access to the biliary tree and the distal CBD.^4–6 Although this is not commonly practised, some publications have reported catheterisation of the cystic duct for placement of an external biliary drain.^5–7

The indications and contraindications for the transcholecystic access to the biliary tree are shown in box 1 and table 1. One of the main challenges for the percutaneous route in the described case was the lack of intrahepatic duct dilatation. Although the intrahepatic approach can be used even in a non-dilated intrahepatic system, our approach was easier and safer for the patient. Using the distended gall bladder and gastropexy sutures, this prevented the need for multiple punctures into a non-dilated system. As the patient was septic, this also had increased risk of repeated punctures; therefore, this was considered a safer approach.

Box 1. Indications for intervention through the gall bladder and cystic duct^4–7 .

• Cholecystectomy not appropriate.

• Failed endoscopic retrograde cholangiopancreatography.

• Metastatic hepatic disease, intervention would risk seeding along the tract.

• Hepatic cysts, difficulty in guiding the wire through the fluid cavity.

• Non-dilated intrahepatic duct.

Table 1.

Contraindications for intervention through the gallbladder (transcholecystic approach)^5–7

Contraindications for intervention through the gallbladder (transcholecystic approach)
Anatomical	Reasoning
Interposed bowel between the abdominal wall and the gallbladder.	Preventing safe access to the gallbladder (risk of perforation, therefore perioperative ultrasound-guided insertion of the needle is essential).
Decompressed gallbladder.	This may be overcome by ensuring the patient is nil by mouth from the night before the intervention, which allows maximal distension of the gallbladder.
Gallbladder filled with calculi.	Such that a guidewire cannot be negotiated through to the cystic duct, or the drain cannot be accommodated within.
Pathology
Untreated or severe bleeding risk.	The main parameters to check include the following: Haemoglobin >70 g/L. Platelets >50×109/L. INR <1.5.
Gallbladder cancer.	Risk of seeding along the tract.

INR, International Normalised Ratio.

Another potential option for similar cases may be the use of endoscopic ultrasound-guided gallbladder drainage with a transgastric or transduodenal gallbladder puncture and insertion of lumen apposing the metal stent for gallbladder decompression, but manipulation via the distal CBD may be very challenging. A review by Boregowda et al ⁸ found the limited available evidence is promising for transgastric or transduodenal gallbladder puncture and subsequent stent insertion; however, prospective, large multicentre studies are needed before endoscopic-guided gallbladder drainage can be used as a first-line treatment instead of percutaneous cholecystostomy as a bridge therapy to surgery.

The primary use of gastropexy sutures has not been previously described by other authors and allowed steady manoeuvrability of the guidewire via the cystic duct, making the procedure very straightforward given that navigating the guidewire through the cystic duct may be challenging. In our case we could presume that the passage of the gallstone may have caused some dilatation of the Heister’s valves; however, the tortuosity of the cystic duct may cause wire kinking and looping, and good support at the gallbladder access is of paramount importance (figure 2A–C). Gastropexy sutures also help to reduce the risk of leakage at the puncture site until the tract is mature.

In cases where the intrahepatic ducts are collapsed, access to the biliary tree is still possible. However, this case demonstrates an alternative approach which was sought to reduce the risk of multiple punctures in a patient with sepsis. A transcholecystic approach to treat distal biliary duct obstruction can be considered as an alternative and is a safe and technically feasible option. This route can be considered especially when there is contraindication, such as in this case secondary to biliary sepsis and difficulty due to collapsed intrahepatic bile ducts.

Learning points.

• Percutaneous transhepatic biliary drainage is an established, minimally invasive procedure for patients with acute cholangitis in case of failure of endoscopic retrograde cholangiopancreatography.

• When transhepatic approach is not feasible, access to the biliary tree via the gallbladder and subsequent cannulation of the common bile duct has been reported as a safe alternative.

• Access to the biliary tree via the gallbladder may also be considered in case of lack of dilatation of the bile ducts and obstruction at the level of the distal common bile duct.

• Manipulation via the cystic duct might be challenging due to significant tortuosity and lack of stability of the gallbladder; this may be resolved by fixing the mobile gallbladder to the abdominal wall with percutaneously inserted gastropexy sutures.

• In case of percutaneous access to the gallbladder, the access catheter needs to be kept in situ for at least 4 weeks and be removed after tract maturation.