Percutaneous cholecystoscopy and internal rendezvous for ... - IJP

BRIEF REPORTS
Percutaneous cholecystoscopy and internal rendezvous for removal of
gallstones and common bile duct stones (with video)
Eduardo A. Bonin, MD, MSc, Tercio L. Lopes, MD, Todd H. Baron, MD, FASGE
Rochester, Minnesota, USA
Acute cholecystitis may be successfully managed by
cholecystostomy, either temporarily or permanently. 1,2
Concomitant common bile duct (CBD) stones are present
in 14% to 21% of patients. 3,4 We describe a case of cholecystolithiasis
with concomitant choledocholithiasis successfully
treated by percutaneous endoscopic cholelithotomy
and internal rendezvous to allow ERCP and CBD
stone removal.
CASE REPORT
A 67-year-old man initially presented with acute calculous
cholecystitis and was deemed a nonsurgical candidate
because of severe coronary artery disease with
left main coronary artery stent, ischemic cardiomyopathy,
ventricular tachycardia with implantable cardiodefibrillator,
hypertension, diabetes mellitus, and chronic
kidney disease. He was managed with US-guided percutaneous
gallbladder drainage. After clinical improvement,
gallstones were removed percutaneously, although impacted
cystic duct stones could not be removed (Fig. 1).
After the last attempt to remove the gallstones percutaneously,
the patient developed acute necrotizing pancreatitis,
which was successfully treated with serial direct endoscopic
necrosectomies. A repeat cholecystogram revealed
concomitant CBD stones (Fig. 2).
The planned endoscopic approach was ERCP and
CBD stone removal followed by endoscopic removal of
the cystic duct stones via the cholecystostomy tract.
After informed consent and with the patient under general
anesthesia, an ERCP was performed by using a
standard duodenoscope (TJF 160VL; Olympus America,
Center Valley, PA). Biliary cannulation (including precut
sphincterotomy) failed because of difficult anatomy and
an intradiverticular papilla. Video 1 (available online at
www.giejournal.org) shows the subsequent endoscopic
approach. The duodenoscope remained in place. The indwelling
cholecystostomy tube (16F) was removed, and a
4.9-mm upper endoscope (GIF N180; Olympus America)
was advanced into the gallbladder through the cholecystostomy
tract. All of the impacted cystic duct stones were
retrieved by using a pediatric Dormia basket. Contrast
material injection showed no residual filling defects and a
patent cystic duct. For internal rendezvous, a 260 cm–long
Figure 1. In this fluoroscopic image, contrast material injected through
the cholecystostomy catheter demonstrates impacted stones within the
cystic duct (white arrow). An indwelling double-pigtail stent from prior
transgastric necrosectomy can be seen.
0.035-inch angled hydrophilic guidewire (Glidewire; Boston
Scientific, Natick, Mass) was advanced through the
working channel of the endoscope while the tip was
positioned at the cystic duct opening. The wire passed
through the cystic duct into the duodenum and was
grasped with a forceps and withdrawn through the duodenoscope
(Figs. 3 and 4). ERCP then proceeded in the
usual fashion with sphincterotomy and CBD stone extraction.
A percutaneous tube was not replaced into the gallbladder.
Total procedure time was 80 minutes. Fever and
bacteremia after the procedure required 2 days’ hospitalization.
Within 2 weeks, the cholecystostomy site closed.
The patient remains well without further pancreaticobiliary
symptoms 1 year later.
DISCUSSION
Gallstones can be removed with percutaneous fluoroscopically
guided 5 and endoscopic techniques 6 through a
www.giejournal.org Volume xx, No. x : 2011 GASTROINTESTINAL ENDOSCOPY 1

Brief Reports
Figure 2. In this fluoroscopic image, contrast material injected through
the cholecystostomy catheter demonstrates bile duct stones (white
arrow).
Figure 4. Schematic drawing depicting successful transcystic and transpapillary
guidewire placement. This was achieved by advancing the guidewire into the
cystic and bile ducts and finally into the duodenum, where it was then grasped
and withdrawn through the working channel of the duodenoscope.
DISCLOSURE
T. Baron is a consultant for Olympus America. No other
financial relationships relevant to this publication were
disclosed.
Abbreviation: CBD, common bile duct.
REFERENCES
Figure 3. For the internal rendezvous procedure, a 0.035-inch, hydrophilic
biliary guidewire was advanced into the cystic duct. The guidewire
was passed through the valves of Heister, into the bile duct, then finally
into the duodenum.
mature cholecystostomy tract with technical success rates
of 94% to 96%. 5,6 We performed percutaneous endoscopic
cholecystolithotomy to remove difficult, impacted cystic
duct stones with complete gallbladder clearance. Because
retrograde cannulation was not possible even after precut
papillotomy, an internal rendezvous through the gallbladder
allowed successful ERCP with clearance of choledocholithiasis.
We are unaware of prior reports of such an
internal rendezvous technique, which can be useful for
endoscopically accessing the biliary tree to relieve biliary
obstruction of any etiology and/or to treat biliary leaks in
patients with indwelling, mature percutaneous cholecystostomy
tubes.
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cholecystectomy. Am Surg 2010;76:708-12.
3. Coelho JC, Buffara M, Pozzobon CE, et al. Incidence of common bile duct stones
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4. Chiarugi M, Galatioto C, Lippolis PV, et al. Simultaneous laparoscopic
treatment for common bile duct stones associated with acute cholecystitis:
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5. Kim YH, Kim YJ, Shin TB. Fluoroscopy-guided percutaneous gallstone removal
using a 12-fr sheath in high-risk surgical patients with acute cholecystitis.
Korean J Radiol 2011;12:210-5.
6. Ohashi S. Percutaneous transhepatic cholecystoscopic lithotomy in the managementofacutecholecystitiscausedbygallbladderstones.DiagnTherEndosc
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Department of Medicine, Division of Gastroenterology & Hepatology, Mayo
Clinic, Rochester, Minnesota, USA.
Reprint requests: Todd H. Baron, MD, 200 First Street SW, Rochester, MN 55905.
Copyright © 2011 by the American Society for Gastrointestinal Endoscopy
0016-5107/$36.00
doi:10.1016/j.gie.2011.07.074
2 GASTROINTESTINAL ENDOSCOPY Volume xx, No. x : 2011 www.giejournal.org