A 63 year old male with hepatic cysts was diagnosed with metastatic pancreatic cancer. Interoperative biopsy at the time of diagnostic laparoscopic surgery confirmed hepatic metastases. In an indwelling 10mm by 6cm uncovered filary metal stent, he presented with fever, severe abdominal pain, hypotension, increased liver enzymes after a course of palliative chemotherapy. A CT scan a month prior showed a 10 by 10 cm cystic lesion in the liver. A CT scan on admission showed gallbladder wall thickening suggestive of cholecystitis, an enlarged cyst, and pneumobilia suggestive of stent patency. The liver cyst was now 13.7 by 10.7 cm. A previously placed uncovered filary stent was in good position, but appeared partially occluded at its entrance. A clandrogram showed some amount of stent restenosis within its mid portion. The gallbladder could not be filled. The intrapathic ducts were non-dilated. There was one long stricture from the left intrapathic duct, consistent with extrinsic compression in the area. We balloon dilated the stent with an 8-10mm dilating balloon, followed by placement of a 7 French 7cm double pigtail stent into the right intrapathic duct. On linear echoendoscopy, an anechoic lesion consistent with a simple cyst was seen. From the stomach, the large liver cyst was visualized with some layering echogenic material within the cavity. Readily apparent was the markedly abnormal gallbladder. The wall was thickened with dense echogenic material within the gallbladder and a large stone, as was noted on this cross-sectional imaging. Given the CT scan findings, occluded cystic duct on ERCP, and sonographic acute cholecystitis, a decision was made to treat endoscopically. Doppler reviews from the duodium confirmed a safe window for transluminal decompression. The gallbladder lumen was adequate to deploy a 15mm cotter-enhanced lumen-opposing metal stent, which was used to puncture the gallbladder by direct technique. The internal flange was deployed, followed by the external flange. Here fluoroscopy demonstrates deployment with a wire placed through the lambs. Frank paused strain from the gallbladder, which was cultured. The lambs was in good position. A 7 French 3cm double pigtail stent was placed through the lumen-opposing metal stent. We then turned our attention to the enlarged hepatic cyst. Given that his severe pain seemed out of proportion to cholecystitis alone, and because of the cyst-wrapped enlargement, we chose to assess if the cyst was secondarily infected. From the stomach the large cystic liver lesion was revisualized. The window was selected, carefully avoiding vessels in the gastric wall, peritoneum, and within the liver itself. Scope position was challenging given that we were midway down in the body of the stomach. Eventually with a stable position, a 19 gauge needle was placed into the cyst. We had to rotate the scope after the initial puncture to avoid the hepatic vein and gain entry into the cyst. A 6 frank pus was aspirated confirming our suspicion that this was secondarily infected. Likely the infectious source was from cholecystitis, and the abscess would benefit from drainage. A guide wire was coiled into the abscess through the 19 gauge needle, sonographically shown here. This was followed by a tract dilation of the hepatic parenchyma and the gastric wall with a 4x4 balloon, endoscopically shown here. Next we deployed a 10mmx10cm fully covered billiary metal stent. The final deployment demonstrated here. Approximately half a liter of purulent material drained from the cyst and was suctioned out through the scope. A 7 french 10cm pigtail stent was placed through the metal stent. Final results shown here on endoscopy and fluoroscopy. He was pain free the next morning. Klebsiella pneumoniae was cultured from both the cyst fluid and the gallbladder aspirate. He completed a 4 week course of antibiotics as per infectious disease. The plan is to leave all 3 metal stents in long term. This will provide his triple drainage, billiary, gallbladder and hepatic cyst. While aspiration of a cyst can help confirm if it is infected, endoscopic drainage can be performed with the same procedure to avoid the need for percutaneous drains. When pain seems out of proportion to the primary billiary disease process, a secondarily infected hepatic cyst could be the cause. If needle access is difficult because of the hepatic vessels in the way, dynamic tract changes can be made while passing the needle to avoid the vessels. Patients with indwelling billiary stents are most commonly septic from cholangitis, cholecystitis can also cause sepsis in patients with advanced pancreatic cancer. Rarely hepatic cysts can become secondarily infected by cholecystitis. For management these cases can be treated with triple drainage using 3 different types of hepatic billiary stents.

hepatic cysts

metastatic pancreatic cancer

endoscopic procedures

gallbladder complications

pain relief