Biliary stent placement via percutaneous non surgical cholecystostomy

A 57-year-old man presented with a 2-month history of abdominal pain, jaundice and weight loss of 10kg. There was no relevant past medical history. Abdominal CT showed an enlarged pancreas and right adrenal gland, as well as ascites. Exploratory laparotomy revealed tumour extending through the pancreas and involving the duodenum, with seedling involvement of the gallbladder and porta hepatis. An antecolic gastrojejunostomy was performed for gastric decompression. Histopathology demonstrated poorly differentiated adenocarcinoma with prominent vascular invasion. He became progressively more jaundiced and was referred to our institution. Endoscopic retrograde cholangiopancreatography (ERCP) was unsuccessful because tumour involvement of the duodenum prevented air distension. Cannulation of the duodenal papilla and subsequent stenting was not possible. PTC revealed a narrow stricture in the lower CBD (Fig. la.). The intrahepatic ducts were not dilated and attempts to introduce a guidewire were unsuccessful. Using local anaesthetic and premedication with intravenous pethidine, the hepatic surface of the GB was catheterized using an 18 G catheter needle (Cook Denmark) and a right-sided approach in the mid-axillary line. Over a guide wire, a 5 French pigtail Thistle catheter (Cook Denmark) was inserted, coiled in the GB lumen (Fig. lb) and left in situ. The fundus of the GB was then punctured with a second 18 G catheter needle using a subhepatic approach. A guide wire was inserted and coiled in the GB lumen. A 9 French track was made to the GB fundus using concentric Teflon dilators. Using a fine 8 French Burhenne steerable catheter, a Terumo guide wire was inserted through the cystic duct and CBD and into the duodenum (Fig. lc). A straight 5 French catheter was inserted over the wire into the duodenum. The Terumo wire was replaced by an Amplatz superstiff guidewire. A 10 French Teflon pigtail stent was placed over the wire across the obstruction into the duodenum, and positioned using a pusher, so that it lay outside the cystic duct in the CBD proximally, and in the duodenum distally (Fig. ld). The 5 French GB catheter was removed 24 h later, after emptying the gallbladder of bile and residual contrast. The patient survived four months without recurrence of jaundice.