CASE REPORT

Interval Biliary Stent Placement Via Percutaneous UltrasoundGuided Cholecystostomy: Another Approach to PalliativeTreatment in Malignant Biliary Tract Obstruction

James Harding Æ Alex Mortimer Æ Michael Kelly ÆEric Loveday

Received: 2 May 2009 / Accepted: 30 June 2009 / Published online: 18 August 2009

� Springer Science+Business Media, LLC and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2009

Abstract Percutaneous cholecystostomy is a minimally

invasive procedure for providing gallbladder decompres-

sion, often in critically ill patients. It can be used in

malignant biliary obstruction following failed endoscopic

retrograde cholangiopancreatography when the intrahepatic

ducts are not dilated or when stent insertion is not possible

via the bile ducts. In properly selected patients, percuta-

neous cholecystostomy in obstructive jaundice is a simple,

safe, and rapid option for biliary decompression, thus

avoiding the morbidity and mortality involved with per-

cutaneous transhepatic biliary stenting. Subsequent use of a

percutaneous cholecystostomy for definitive biliary stent

placement is an attractive concept and leaves patients with

no external drain. To the best of our knowledge, it has only

been described on three previous occasions in the pub-

lished literature, on each occasion forced by surgical or

technical considerations. Traditionally, anatomic/technical

considerations and the risk of bile leak have precluded such

an approach, but improvements in catheter design and

manufacture may now make it more feasible. We report a

case of successful interval metal stent placement via

percutaneous cholecystostomy which was preplanned and

achieved excellent palliation for the patient. The pros and

cons of the procedure and approach are discussed.

Keywords Percutaneous cholecystostomy � Stent �Palliative � Biliary obstruction

Introduction

A 74-year-old man presented to our institution with a 4-

week history of upper abdominal distension, weight loss,

nausea, vomiting, and painless jaundice. He was a retired

farmer, previously fit and well. There was no other relevant

history of note.

Initial examination revealed frank jaundice with no

stigmata of chronic liver disease. There was tenderness in

the epigastrium and the suggestion of a palpable liver edge

but no other significant finding. Investigations revealed

altered liver chemistry with an obstructive picture (biliru-

bin, 249 lmol/L; ALT, 608 IU/L; ALP, 274 IU/L).

Abdominal ultrasound showed a dilated extrahepatic bili-

ary tree, multiple liver lesions, and the suggestion of a

pancreatic mass. CT findings were in keeping with meta-

static pancreatic cancer.

The patient became increasingly jaundiced and symp-

tomatic, the bilirubin rising to 402 lmol/L. Endoscopic

retrograde cholangiopancreatography (ERCP) and wash-

ings confirmed the diagnosis of pancreatic adenocarcinoma

but it was not possible to cross the common bile duct

stricture at ERCP to enable palliative biliary stent place-

ment. The options for further radiological management

were discussed while awaiting formal management deci-

sions from the regional multidisciplinary team (MDT)

meeting.

It was felt that in the presence of multiple hepatic

metastases and nondilated intrahepatic ducts, the risks of

attempting percutaneous transhepatic cholangiography

(PTC) and chance of success outweighed the possible

J. Harding (&) � A. Mortimer � E. Loveday

Department of Radiology, North Bristol NHS Trust,

Frenchay Hospital, Beckspool Road, Bristol BS16 1LE, UK

e-mail: drjames.harding@btinternet.com

M. Kelly

Department of General Surgery, North Bristol NHS Trust,

Frenchay Hospital, Beckspool Road, Bristol BS16 1LE, UK

123

Cardiovasc Intervent Radiol (2010) 33:1262–1265

DOI 10.1007/s00270-009-9680-x

benefit. Following discussion with and consent of the

patient, an ultrasound-guided percutaneous cholecystos-

tomy was performed using a micropuncture kit (Angio-

tech). Over a standard J wire, the track was dilated to 8 Fr,

and an 8-Fr locking pigtail drain (Flexima; Boston Scien-

tific) sited in the gallbladder body (Fig. 1). This procedure

was well tolerated and resulted in biochemical improve-

ment in the patient’s jaundice (bilirubin fell to 170 lmol/L

within 6 days).

At 7 days postcholecystostomy we attempted biliary

stent placement via the cholecystostomy (Fig. 2). The drain

was removed over a wire and a 7-Fr sheath sited at the

percutaneous puncture site. Passage of a hydrophilic

guidewire (Terumo) and 45-cm, 5-Fr biliary manipulation

catheter (Cook) enabled access via the cystic duct and

common bile duct and across the stricture to the duodenum.

Contrast cholangiography in AP, LAO, and RAO projec-

tions was performed to determine the point of confluence

of the cystic duct and common hepatic duct and to dem-

onstrate the length of common bile duct available for stent

placement.

Stiff wire exchange (Amplatz) then allowed straight-

forward passage of a 100 9 40-mm Nitinol-covered metal

biliary stent (Niti–S; Taewoong Medical) across the stric-

ture into a good position, deployed below the cystic duct. A

second stent was placed coaxially to extend the stented

segment and ensure adequate drainage. There was no dif-

ficulty passing the stent delivery system through the cystic

duct. The biliary tree was objectively decompressed and

the stent draining freely. An 8-Fr drain was resited into the

gallbladder to prevent bile leak to the peritoneum but this

was removed successfully at 48 h.

The patient continued to improve clinically and was

discharged 6 days post stent placement. Both the patient

and his wife were pleased with the outcome and felt that

the intervention had been worthwhile. He died 6 weeks

later at home. Nursing staff reported a very good palliative

effect from the radiological procedures. When last mea-

sured, the serum bilirubin had fallen to 35 lmol/L.

Discussion

Percutaneous cholecystostomy represents a minimally

invasive procedure for providing gallbladder decompres-

sion, often in critically ill patients. Indications for this

procedure include calculous and acalculous cholecystitis,

gallbladder perforation, malignant obstruction, percutane-

ous biliary stone removal, diagnostic imaging of the gall-

bladder/biliary ductal system, and biliary duct drainage in

distal bile duct obstruction when the intrahepatic ducts are

not dilated or when stent insertion is not possible via the

bile ducts [1]. In properly selected patients, percutaneous

cholecystostomy in obstructive jaundice is a simple, safe,

and rapid option for biliary decompression [2]. Difficult or

failed PTC is a traumatic procedure with well-known

morbidity and mortality, predominantly related to the

number of attempts at duct puncture and delayed external

drainage before stent insertion [3].

The relative risks of PTC in the particular clinical sce-

nario we report (without intrahepatic duct dilatation but

rapidly worsening clinical picture and a symptomatic

patient keen to proceed) made percutaneous cholecystos-

tomy an attractive option. Though not without risk, it could

act as definitive drainage when patients have a limited life

expectancy or act as a bridge to internal stent placement if

technically possible.

There are very few reports of such an approach to

internal common bile duct stenting. Interventional proce-

dures through the gallbladder have traditionally been more

difficult than those through the liver because of the cystic

duct diameter and valves of Heister interposed between the

initial entry point and the final working location. The cystic

duct has a low insertion in some individuals so inadvertent

deployment of the upper end of the stent in the cystic duct

would be hazardous and may compress the adjacent com-

mon hepatic duct. A contrast study at cholecystostomy

defines the anatomy to enable further decision making.

Dawson et al. [4] reported the first successful case in a

patient with metastatic breast cancer with an unresectable

pancreatic mass extending to the porta hepatis. They

reported that neither choledochojejunostomy norFig. 1 Percutaneous cholecystostomy placement confirming distal

common bile duct stricture and nondilated intrahepatic bile ducts

J. Harding et al.: Interval Biliary Stent Placement 1263

123

pancreaticojejunostomy could be performed surgically and

biliary drainage was achieved via surgical placement of a

24-Fr cholecystostomy catheter. The authors were then

able to place a metal stent into the common bile duct

through such a relatively large access portal. Hickey et al.

[5] reported a further case but proceeded to stent via a

cholecystostomy after PTC and failed transhepatic duct

cannulation. Subsequently, Ramsay et al. [6] reported a

case where, despite successful PTC and duct cannulation,

an external drain was left in situ within the intrahepatic

ducts, with resulting system decompression, but drain

displacement resulted in incomplete drainage. Subsequent

derangement of that patient’s clotting and a further failed

attempt to puncture intrahepatic ducts resulting in hema-

toma forced another effort at biliary decompression via

percutaneous cholecystostomy. The authors managed to

reach the duodenum but stent placement was performed in

a combined procedure via ERCP.

To the best of our knowledge, this is the first reported

instance of internal biliary stent placement via a chole-

cystostomy in such a premeditated manner, deliberately

avoiding the risks of hepatic puncture and the necessity for

surgical intervention or a combined procedure with

endoscopy. We suggest that in clearly palliative cases of

distal common bile duct obstruction with nondilated

intrahepatic ducts and a dilated distal biliary system, per-

cutaneous cholecystostomy is a perfectly reasonable first

step in achieving symptom control as long as an ongoing

clinical management pathway is agreed on in advance. A

subsequent attempt to internalize a biliary stent using

modern catheters and wires is possible when the anatomy is

favorable.

Acknowledgment We thank Rachel Warman, Upper GI Cancer

Nurse Specialist, North Bristol NHS Trust, for assistance with

information and correspondence.

References

1. Ginat D, Saad WE (2008) Cholecystostomy and transcholecystic

biliary access. Tech Vasc Interv Radiol 11(1):2–13

2. VanSonnenberg E, D’Agostino H, Casola G et al (1990) The

benefits of percutaneous cholecystostomy for decompression of

selected cases of obstructive jaundice. Radiology 176:15–18

Fig. 2 A Wire access obtained

via cholecystostomy. B Cystic

duct and common bile duct

reached with catheter and wire.

C Position confirmed in

duodenum. D Successful stent

placement with good drainage

and cholecystostomy replaced

1264 J. Harding et al.: Interval Biliary Stent Placement

123

3. Mueller PR, Ferucci JT, Teplick SK (1985) Biliary stent endopros-

thesis: analysis of complications in 113 patients. Radiology 156:

637–639

4. Dawson SL, Girard MJ, Saini S, Mueller PR (1991) Placement of a

metallic biliary endoprosthesis via cholecystostomy. AJR 157:

491–493

5. Hickey NAJ, Kiely P, Farrell TA, McNulty JG (1998) Biliary stent

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Radiol 53:915–916

6. Ramsay DW, Newland CJ, Townson GA, Wicks AC (1999)

Cholecystostomy: an unusual approach to stenting of a distal common

bile duct stricture. Eur J Gastro Hepatol 11:1429–1430

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