Keywords
cholecystogastrostomy - endoscopic ultrasound - permanent external biliary catheter
External biliary drainage, a salvage procedure after failure of endoscopic retrograde cholangiopancreatography (ERCP), is associated with risk of permanent external biliary catheter. Permanent external biliary catheter is a troublesome situation and leads to deterioration in quality of life. A 70-year-old male presented with pruritus and jaundice. Imaging was suggestive of obstruction due to mass lesion at liver hilum, suggesting diagnosis of cholangiocarcinoma. During ERCP, wire could not be negotiated across the stricture; hence, rescue percutaneous transluminal biliary drainage (PTBD) was done. PTBD catheter could not be internalized because of non-negotiable stricture. As the guidewire from the PTBD site was repeatedly entering the gall bladder, hepaticocholecystogastrostomy was performed to internalize the PTBD catheter. PTBD catheter was first passed into collapsed gall bladder lumen, followed by saline infusion, leading to adequate distension of gall bladder ([Fig. 1a]). Endoscopic ultrasound (EUS)-guided cholecystogastrostomy was done using 15 mm × 10 mm lumen-apposing stent (Hot axios, Boston scientific, Marlborough, USA) ([Fig. 1b]); through the metal stent, 10Fr, 5 cm double pigtail plastic stent (C-Flex, Boston Scientific, Spencer, USA) was placed. Next day, from the PTBD site, guidewire was negotiated from right hepatic duct (RHD), across the gall bladder, through the cholecystogastrostomy stent into the gastric lumen ([Fig. 2a]), followed by self-expandable metallic stent (SEMS) placement (10 mm, 8 cm, Boston Scientific, Natick, MA, USA) ([Fig. 2b]) through the transhepatic route, connecting RHD to gastric lumen. PTBD catheter was removed next day, and further clinical course was uneventful. Failure to internalize the catheter is a common problem with PTBD.[1]
[2] Various techniques[3] have been used to internalize the external catheter. Law et al[3] reported a case where EUS-guided hepaticogastrostomy was performed to internalize the left-sided PTBD catheter. In the present case, PTBD was done on right biliary system; hence, EUS guided hepaticogastrostomy was not possible. As the guidewire from the PTBD site was entering in gall bladder lumen, this was used as an opportunity to internalize the external biliary catheter.
Fig. 1 (a) Transgastric endoscopic ultrasound showing distended gall bladder; fluid was injected through percutaneous transluminal biliary drainage (PTBD) catheter to distend the gall bladder. (b) Cholecystogastrostomy; metal stent placed between gall bladder and gastric antrum.
Fig. 2 (a) Guidewire placed across the PTBD site through the gall bladder in gastric lumen. Double pigtail stent across the cholecystogastrostomy metal stent can also be seen. (b) Biliary self-expandable metallic stent (SEMS) placed through the percutaneous transluminal biliary drainage (PTBD) site. Internal end of the stent can be seen in the gastric lumen; biliary stent is surrounded by cholecystogastrostomy stent. Wider stent is cholecystogastrostomy site, lumen-apposing stent.
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Vikas Singla
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Writing the manuscript
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Ajit Kumar Yadav
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Collection of all the images and writing of manuscript
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Anil Arora
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Designing the work and writing the manuscript
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Arun Gupta
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Revision of manuscript
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