Bouncing Off the Balloon: A New Trick for Selective Cystic Duct Cannulation

Abstract

Introduction: Management of acute cholecystitis in non-surgical or high-risk candidates includes endoscopic (transpapillary or transmural stenting) or percutaneous drainage of the gallbladder (GB). Endoscopic cannulation of the cystic duct (CD) for transpapillary GB drainage in such cases can be technically challenging and difficult, given narrowing of cystic duct orifice from edema, stones and valves in the cystic duct, and angulation of the cystic duct takeoff. Here we describe a novel technique, using no special equipment that can be utilized in cases of angulated CD takeoff. Case Description: A 47-year-old woman was admitted with acute cholecystitis and choledocholithiasis. Her vitals were stable with no signs of sepsis. Her WBC was 7.7 X 103/dl, AST 78 unit/L, ALT 267 unit/L, ALP 207 unit/L, total bilirubin was 1.2 mg/dl. Given her morbid obesity (BMI 53) and multiple comorbidities (history of recent uterine infection with perforation, multiple intra-abdominal abscesses, and a diversion colostomy) she was deemed not a surgical candidate for cholecystectomy. Subsequently, she underwent an endoscopic retrograde cholangiography (ERC) with successful mechanical lithotripsy and balloon extraction of multiple common bile duct (CBD) stones. Selective CD cannulation was then attempted; however, was unsuccessful despite multiple attempts using different guidewires and catheters given the downward angulation (Image 1) of the CD takeoff that made it technically challenging. A 15 mm extraction balloon was inflated in the distal common hepatic duct (1 cm proximal to the CD orifice) and a 0.035-inch guidewire was inserted into the CBD alongside the extraction balloon catheter. The guidewire was further advanced into the bile duct allowing the guidewire to recoil (bounce) off the balloon, and was carefully manipulated into the angulated CD takeoff (Image 2). Contrast injection showed filling defect in the neck of the gallbladder. Pus was seen draining from the major ampulla after CD cannulation. A transpapillary 7 Fr x 22 cm double-pigtail plastic stent was successfully placed across the CD with the internal pigtail in the gallbladder lumen (Image 3).1323_A.tif Figure 1: No Caption available.1323_B.tif Figure 2: No Caption available.1323_C.tif Figure 3: No Caption available.Discussion: There is a paucity of techniques describing CD cannulation. These include using intraductal ultrasound or cholangioscopy for guidance, however, such devices may not be readily available. We believe our novel and simple method can be utilized for selective CD cannulation in such difficult cases.