Tips and tricks for endoscopic transpapillary gallbladder drainage

Abstract

Percutaneous gallbladder drainage has traditionally been the reference standard treatment for cholecystitis in patients deemed unfit for surgery. Endoscopic transpapillary gallbladder drainage has emerged as a reliable alternative that offers an internal, incisionless option in nonsurgical patients. The aim of this study was to describe techniques for successful selective cystic duct cannulation and gallbladder drainage during ERCP. A series of endoscopic transpapillary gallbladder procedures is shown, including endoscopic and fluoroscopic video and images. Each case highlights best practices, devices, and techniques to aid with successful completion of challenging cases. Standard cystic duct cannulation and gallbladder access is described using a standard catheter and a 0.035-inch angled guidewire. Challenges to selective cystic duct cannulation are overcome using various approaches, including using a rotatable catheter system, downsizing to a smaller guidewire, occluding the proximal common hepatic duct with an occlusion balloon, and directly intubating the cystic duct using peroral cholangioscopy. Dilation of the cystic duct is performed using standard devices designed for biliary intervention, but smaller, percutaneous angioplasty balloons are used for small ducts and severe strictures. After dilation, a plastic, double-pigtail stent is deployed across the papilla, and access is reobtained in a similar fashion to place a second, parallel stent. To eliminate the need to re-access the gallbladder after initial stent deployment, a cytology brush catheter is repurposed to obtain dual-wire access within the gallbladder before initial stent deployment. When the fundamentals of ERCP and the techniques described here are used, endoscopic transpapillary gallbladder drainage can be performed safely and effectively to treat cholecystitis in patients who are not surgical candidates.