This ASG video tip is brought to you by an educational grant from Braintree, a part of Cibela Pharmaceuticals, makers of SUTAB. I want to talk also a little about gallbladder drainage. You know, ERCP is used to drain the gallbladder. Back in the old days, we didn't do this, but we're called upon for this more and more as we have become facile to it. And there are easier ways to get this done than others. Usually, this is done to treat acute cholecystitis in lieu of surgery and in lieu of percutaneous cholecystostomy drain placement. In radiology, a lot of surgeons would prefer to do a one-step laparoscopic cholecystectomy in a gallbladder that's been cooled down by stenting rather than going in and doing potentially a lap converted to open with a hot gallbladder. So this is something that we do frequently in my practice and many others. What's done is wire access has gotten up the distal common bile duct across the cystic duct into the gallbladder, and then we place one or more seven French double pigtail stents. Ideally, these are usually 10 or 12 centimeters in length. We prefer to place more than one stent. We have some budding data that demonstrates much better durable patency long term if you put more than one stent in. If we can't, we may swap it out at six months to a year if need be. You may have to dilate the cystic duct if there's a stricture there. Sometimes I will just routinely four millimeter balloon dilate the cystic duct just to make the the stent easier to get up there without a struggle. To get up the cystic duct though, you usually need to spin an angled guide wire. You're usually best off using a hydrophilic guide wire, so get familiar in using this device. Wet it well, use it through a balloon catheter, learn to spin it between your index finger and your thumb or your index and middle finger and your thumb like a helicopter there, and that will help you ascend through the valves of hyster and the cystic duct, get into the fundus of the gallbladder, do your balloon dilation of the cystic duct, and then get your stent in. I almost always use a four millimeter balloon. If the stricture is too tight for that, I'll have to swap that 035 wire out for an 018 wire, and over that I'll use a coronary angioplasty balloon like a three millimeter balloon to dilate that cystic duct. And if you have questions about that, I can tackle that later. Okay, I already told you that they're double pigtail stents, seven French if you can, five French if the cystic is too small. I'd like to get more than one seven in if I can, usually a 10 and a 12 centimeter length is all you need to stock. Occasionally, going backwards, I may need a longer stent. There is a 20 centimeter ureteral that I can borrow from the urologists, and that'll work the same way when I need a longer one that isn't available in the biliary toolbox. So here's a quick case presentation. 80 year old woman, recurrent episode, recurrent prior episodes of acute cholecystitis with a gallbladder, still in situ. She has pancreatic cancer with liver and lung mets. She's in hospice. She has a plastic stent already in situ over seven months in the common bile duct. Now she's jaundiced. She's pruritic. She needs chemotherapy. They can't give it with a bili of eight and a half, and the CT now suggests hyper enhancement and fat stranding around the bile duct as well as they distended, looks like I can't spell there, an edematous gallbladder consistent with cholangitis and acute cholecystitis. So they want us to exchange the obstructed biliary stent and consider endoscopic gallbladder drainage because she's not a surgical candidate. So here's the occluded plastic stent in the common duct. Here's the gallbladder that is presumably also obstructed and infected. There's a liver met on her CT from her panxia. There's a stone in her gallbladder that is probably part of the problem with her acute cholecystitis causing obstruction of the gallbladder. There's your distended gallbladder, the thickened wall, the enhancement around it, acute cholecystitis. So we've got a wire, an angled glide wire, an angled hydrophilic wire that we have spun up the cystic duct into the fundus of the gallbladder here. Push as much wire up there as you need so that if the wire slips back, you haven't lost access. Now I'm going in with a four millimeter balloon dilator. You can see the radiopaque markers on either end. And we're going to inflate that balloon. You don't always have to inflate it to burst pressure. I'll frequently go to about half that. If I don't see a waste, the balloon looks like it's fully inflated, that's enough. And then once that balloon dilation is done, I'll swap that balloon out. And if I don't need to do a brushing of a suspicious cystic duct structure, I'll go right in with that double pigtail stent. There's the tip of it going there. And once you're satisfied it's in a good position, start to pull that wire back or ask your assistant to do so. As you get to the tapered and softer part of the wire, that in that pigtail that's in the gallbladder will take on its curled configuration, then pull the wire and you are done. Okay, so that was the fluoroscopic view. Here I've got a second stent going in on that patient because it's destination therapy. She doesn't ever want to have to come back. She'd like to live the rest of her life out with her metastatic disease without having to come back for another ERCP. So two transcystic stents. So there's that second stent going in. Don't push that stent too far up. You don't want it to in-migrate. Okay, and then push it out of the scope and you'll have two gallbladder transcystic stents in for drainage for destination therapy. Okay, I didn't like how that one was positioned, so a little cosmesis here on our placement using a rat tooth to pull it back just a smidge to make it look pretty. You don't have to do that, but if you can, why not.

gallbladder drainage

ERCP

double pigtail stents

acute cholecystitis

complications