To stent the gallbladder, you usually want a double pigtail stent. The last thing that you want is a straight stent in-migrating into the gallbladder. That's going to cause problems. So have a pigtail curl on the proximal end so that it stays in the gallbladder and doesn't out-migrate, but also a pigtail on the distal end so that it doesn't in-migrate into the gallbladder. Most of the time for trans-cystic stenting of the gallbladder, you want a 7-French stent, and the most useful lengths are 10 and 12 centimeter lengths. Sometimes though, for whatever reason, we may want to get a stent all the way out to the fundus of the gallbladder, and in patients with large or long gallbladders, you may need a 20 centimeter, a 7-French 20 centimeter. That's not made as a biliary stent, but it's made as a ureteral stent. So you can use a 7-French 20 centimeter double pigtail ureteral stent as a gallbladder stent as well. Ureteral stents tend to be lubricated with a hydrophilic lubricant that can sometimes make them slide in a little more easily, especially if you are placing two gallbladder stents. That can be useful. So here's a case of an 80-year-old woman with recurrent prior episodes of acute cholecystitis. And so she does have underlying pancreatic adenocarcinoma with liver and lung mets. She's on hospice care. Somebody had put in a plastic biliary stent, common bile duct stent over seven months ago, and I think in the hospice setting, it was forgotten about. She came in jaundiced and also with a history for recent multiple episodes of cholecystitis due to a known gallbladder stone. So they're asking us to place a permanent metallic stent for this elderly lady with metastatic pancreas cancer, but also to stent her gallbladder to prevent future recurrent episodes of acute cholecystitis because she's not a surgical candidate. So here you can see her gallbladder. She has a plastic stent in the bile duct. Here is a liver metastasis on a CT. Here is the stone in the neck of the gallbladder that's been problematic. And we are then asked to place a metal common duct stent. I am going to choose a bare metal stent in this situation because I do not want to occlude her cystic duct with a covered metal stent and risk causing cholecystitis when she's already had that. So I've just navigated an angled 035 hydrophilic guide wire into the gallbladder. And we are then placing a balloon dilator up there, four millimeter balloon dilator. And we are going to inflate that and perform a dilation. As you can see, sometimes dilating a cystic duct that you think was hard for you to get your catheter through gently with a four millimeter balloon. You don't necessarily inflate it to burst pressure. And then here goes one transcystic gallbladder stent. We have a study going on where there appears to be some at least marginal benefit in terms of durable patency if you place two gallbladder stents side by side. So where it is possible, that tends to be our practice. We do tend to place two if there is enough space to do that. Just to show you, here's one stent already in. We're going in with a second one. And sometimes it helps to have a rat tooth to help you make little adjustments in the position of your stent if you want them to lie a certain way. I think I just wanted a certain cosmetic appearance to what the stents look like here. So that was one case. I had another case last week with a 68-year-old with acute cholecystitis and a CT showing gallbladder wall thickening and air in the gallbladder suggestive of emphysematous cholecystitis. And for medical reasons, the surgeons didn't want to touch him and asked us to place stents into the gallbladder. This, unfortunately, was the papillary orifice inside a diverticulum. It took me a little while to get access, but ultimately I did. Here's that 018H 45-degree angled hydrophilic wire. And I'm spinning it and darting it and looping it to try to get through the valves of Hyster gallbladder throughout the cystic duct. And you'll know that you are successful in successfully in the gallbladder once that wire shoots out into the gallbladder and curls itself there. And you can usually follow it right in with your catheter. That'll tend to straighten the cystic duct out. Here it is way out in the gallbladder. And now we've switched out to a thicker wire, an 035 wire. And then ultimately we end up putting in, this cystic duct was only large enough for one gallbladder stent, but it certainly did a nice job. We just performed a sphincterotomy, got into that gallbladder, as you saw in the fluoro. And then here we are inserting the stent. And one of the most gratifying things is when you start seeing the pus draining out of the gallbladder and know that you just did a really, really good thing for this patient. So there you go.

stenting

gallbladder

common bile duct

pigtail stent

acute cholecystitis