Treatment of Symptomatic Cystic Duct Stone in a Pretransplant Cirrhotic Patient

Abstract

Purpose: Cholelithiasis is prevalent in cirrhotic patients. Laparoscopic cholecystectomy is used to treat symptomatic cholelithiasis but is not recommended for those with cirrhosis. Endoscopic gallbladder stent placement has been described for symptomatic cholelithiasis relief in cirrhotic patients, but is technically difficult or impossible if cystic duct anatomy is not amenable to cannulation. This case demonstrates the placement of a cystic duct stent, stent upsizing, and stone removal in a cirrhotic patient with symptomatic cystic duct cholelithiasis. Case: 44 yo male with cirrhosis (Child-Pugh C), acalculous cholecystitis, and prior cystic duct/gallbladder stent presented with biliary pain. ERCP revealed a 5 mm cystic duct stenosis that could not be traversed and a lack of contrast in the gallbladder. A 10 cm 10-Fr biliary stent was placed into the cystic duct proximal to the stricture. Over the next 22 weeks, two ERCs were performed with the replacement of stents proximal to the stricture. At 22 weeks, ERC revealed the localized stenosis in a tortuous cystic duct and three previous 10-Fr, 8.5-Fr, and 7-Fr stents were removed. A 0.035” Jagwire was passed through the stenosis. A 12 cm 5-Fr biliary stent with pigtails was placed into cystic duct and gallbladder. At 24 weeks, ERC showed the stent in place, a diffuse 20 mm stenosis of the cystic duct, and a possible 8 mm gallbladder stone. At 24–32 weeks, two ERCs were performed with upsizing of the gallbladder stents from 5- to 7-Fr. At 38 weeks, ERC revealed a cystic duct of 6 mm in diameter with a filling defect. A second 15 cm 7-Fr stent with pigtails was placed into the gallbladder. At 44 weeks, ERC showed the two 7-Fr stents which were removed. The cystic duct and gallbladder were swept using a basket and balloon with sludge and stone fragments removed. A choledochoscope was passed into gallbladder over a guidewire and demonstrated clearing of the cystic duct, gallbladder, and CBD by direct visualization. Over time, the patient has remained asymptomatic. Conclusions: This case demonstrates a novel technique effectively used in the treatment of a cystic duct stone in a pretransplant cirrhotic patient. Cystic duct stenting with systematic stent upsizing enabled stone removal without surgery. With this approach, cirrhotic patients that are non-operative candidates may have an endoscopic alternative to allow symptomatic relief.