Sp701 Percutaneous Cholecystoscopy and Internal Rendezvous for Removal of Gallstones and Common Bile Duct Stones

Abstract

A 67 year old man presented with cholecystolithiasis and choledocholithiasis. He was deemed a high-risk candidate for surgery due to severe coronary artery disease. The patient initially developed acute calculous cholecystitis which was managed with ultrasound-guided percutaneous gallbladder drainage. Following clinical improvement, interventional radiologists extracted the gallstones using percutaneous techniques. Several gallstones were removed but impacted cystic duct stones remained. The patient developed acute necrotizing pancreatitis one day after the last attempt to remove the impacted cystic duct stones. He was successfully treated with serial endoscopic transgastric necrosectomy procedures. A follow-up cholecystogram revealed the cystic duct stones and concomitant common bile duct stones (CBD). The plan was to use endoscopically remove cystic duct and CBD stones at one procedure. Attempt to cannulate the CBD at ERCP failed. The cholecystostomy tube was removed and a small caliber (4.9mm) endoscope was advanced into the gallbladder through the cholecystostomy tract. The cystic duct stones were successfully retrieved using a pediatric Dormia basket. For internal rendezvous a 0.035” hydrophilic biliary guidewire was advanced through the endoscope in the gallbladder and passed through the cystic duct, CBD and finally into the duodenum where it was then grasped with a forceps and withdrawn through a duodenoscope. A wide papillotomy was performed with complete removal of biliary sludge and CBD stones using a biliary retrieval balloon. Following the procedure the patient was hospitalized for two days due to fever with transient bacteremia. Two weeks after procedure the patient was doing well with no drainage from the cholecystostomy site. A CT scan performed three months after procedure revealed pneumobilia without evidence of gallstones, cystic duct stones or biliary obstruction. He remains well without further pancreaticobiliary symptoms 10 months after the procedure. Percutaneous cholecystoscopy can be used for removal cystic duct stone in patients with an existing cholecystostomy tract. Should retrograde cannulation fail using conventional techniques concomitant common bile duct stones can be removed by using a transcholecystic rendezvous approach.