Gallbladder Stent Placement for Prevention of Cholecystitis in Patients Receiving Covered Metal Stent for Malignant Obstructive Jaundice: A Feasibility Study

Purpose

Covered self-expanding metal stents (CSEMS) have been used for palliation of malignant distal biliary strictures. Occlusion of the cystic duct by CSEMS may be complicated by cholecystitis. This potentially could be prevented by placement of a transpapillary gallbladder stent (GBS).

Patients and Methods

Between 11/2006 and 10/2007, a total of 73 patients (50 male) aged 65 ± 14 years underwent CSEMS placement for palliation of malignant obstructive jaundice. In cases where CSEMS placement caused occlusion of the cystic duct, a 7 French transpapillary pigtail gallbladder stent (GBS) was inserted to prevent cholecystitis.

Results

Of the 73 patients, 18 had a prior cholecystectomy; 34 had the CSEMS placed below the cystic duct insertion. In 19 out of the 21 patients who had a CSEMS covering the cystic duct ostium, GBS placement was attempted, which was successful in 11 individuals (58%). An attempt to access the gallbladder was complicated by wire perforation of the cystic duct in three patients; one patient requiring emergent cholecystostomy tube placement. None of the patients who underwent successful GBS placement developed cholecystitis. One GBS dislodged and was repositioned. Cholecystitis occurred in two (20%) of the ten patients without transpapillary gallbladder decompression who had a CSEMS covering the cystic duct.

Conclusions

The ideal placement of a CSEMS is below the cystic duct insertion. Should the cystic duct ostium be occluded, placement of a GBS should be considered to minimize the risk of cholecystitis.     

Endoscopic transpapillary gallbladder drainage with replacement of a covered self-expandable metal stent

Endoscopic self-expandable metal stent (SEMS) placement has become a standard palliative therapy for pa- tients with malignant biliary obstruction. Acute cholecystitis after SEMS placement is a serious complication. We report a patient with an acute cholecystitis after covered SEMS placement, who was managed successfully with endoscopic transpapillary gallbladder drainage (ETGBD) and replacement of the covered SEMS. An 85-year-old man with pancreatic cancer suffered from acute cholecystitis after covered SEMS placement. It was impossible to perform percutaneous transhepatic gallbladder drainage. After removal of the covered SEMS with a snare, a 7Fr double pigtail stent was placed between the gallbladder and duodenum, subsequently followed by another covered SEMS insertion into the common bile duct beside the gallbladder stent. The cholecystitis improved immediately after ETGBD. ETGBD with replacement of the covered SEMS thus proved to be effective for treatment of patients with acute cholecystitis after covered SEMS placement.     

Cholecystitis after metallic stent placement in patients with malignant distal biliary obstruction.

BACKGROUND & AIMS: Cholecystitis after metallic stent (MS) placement is an issue requiring attention. From our experience, cholecystitis seemed to occur mainly in patients with tumor involvement to the cystic duct orifice. The aim of the present study was to identify risk factors for cholecystitis in patients treated with covered or uncovered MS. METHODS: We analyzed 246 patients who received MS placement (covered MS in 171 and uncovered in 75) between August 1997 and May 2005 for the treatment of unresectable distal malignant biliary obstruction. Causative diseases were as follows: pancreatic cancer in 162, papillary cancer in 10, bile duct cancer in 41, and metastatic nodes in 33 patients. Tumor involvement to orifice of the cystic duct (OCD) was diagnosed based on cholangiography and intraductal ultrasonography. RESULTS: Cholecystitis after MS placement was found in 13 patients (5.3%). There was no significant difference in the incidence of cholecystitis between covered (5.8%) and uncovered (4.0%) MS. By univariate analysis, tumor involvement of the OCD, MS placed above the papilla, and stricture located at midportion were associated significantly with cholecystitis. By multivariate analysis, only tumor involvement of the OCD was a risk factor, with an odds ratio of 47.206 (95% confidence interval, 5.84-381.60). CONCLUSIONS: Cholecystitis after MS placement is associated with tumor involvement to the orifice of the cystic duct, regardless of the type of stent.     

ENDOSCOPIC OCCLUSION OF CYSTIC DUCT USING N‐BUTYL CYANOACRYLATE FOR POSTOPERATIVE BILE LEAKAGE

Bile leak after cholecystectomy is well described, with the cystic duct remnant the site of the leak in the majority of cases. Endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement has a high success rate in such cases. When ERCP fails, options include surgery, and percutaneous and endoscopic transcatheter occlusion of the site of bile leak. Here, we describe a case of endoscopic transcatheter occlusion of a persistent cystic duct bile leak after cholecystectomy using N‐butyl cyanoacrylate glue. A 51‐year‐old man had persistent pain and bilious drainage following a laparoscopic cholecystectomy. The bile leak persisted after endoscopic placement of a biliary stent for a confirmed cystic duct leak. A repeat ERCP was carried out and the cystic duct was occluded with a combination of angiographic coils and N‐butyl cyanoacrylate glue. The patient's pain and bilious drainage resolved. A follow‐up cholangiogram confirmed complete resolution of the cystic duct leak and a patent common bile duct.     

Percutaneous transhepatic gallbladder stenting for recurrent acute acalculous cholecystitis after failed endoscopic attempt

Endoscopic gallbladder stenting is useful palliative therapy for acute cholecystitis in high‐risk patients. Although the success rate of endoscopic gallbladder stenting is 79%–100%, an alternative method has not been reported. We succeeded in employing a method for percutaneous gallbladder stenting (PTGS) and herein describe this new method. A patient with acute acalculous cholecystitis related to ischemic atherosclerotic vascular disease, cholangitis due to Lemmel syndrome, and severe congestive heart failure underwent PTGS through the cystic duct from the gallbladder to the duodenal papilla, because an endoscopic method failed in the treatment of Lemmel syndrome. Because we were unable to place endoscopic transpapillary gallbladder drainage, percutaneous transhepatic gallbladder drainage (PTGBD) was performed and both the cholecystitis and cholangitis ceased. PTGS was performed as an alternative to endoscopic gallbladder stenting. Access to the cystic duct and gallbladder was obtained by the PTGBD route, using a guidewire (0.035‐inch diameter) and seeking catheter (6.5 Fr) under fluoroscopic control. A 7‐Fr 12‐cm double‐pigtail biliary polyethylene stent was placed. The patient remained asymptomatic for 3 months after the PTGS until he died, of an acute recurrent myocardial infarction. This new PTGS placement is an alternative treatment for symptomatic gallbladder disease in patients with increased operative risk when the endoscopic method is unsuccessful.     

Risk factors for cholecystitis after metal stent placement in malignant biliary obstruction

BACKGROUND: Cholecystitis related to metal stent placement is a morbid event. OBJECTIVE: This study evaluated the risk factors of cholecystitis after metal stenting for malignant biliary obstruction. PATIENTS: Between December 1997 and April 2003, 155 patients who were treated with a metal stent for malignant biliary obstruction were retrospectively enrolled. MAIN OUTCOME MEASUREMENTS: The incidence and characteristics of patients with cholecystitis were evaluated and compared with those of patients without cholecystitis. Patient characteristics and tumor or procedure-related data were recorded for the following variables: sex, age, tumor and stent length, stent type (covered vs uncovered), cholangitis before ERCP, degree of gallbladder filling with contrast medium during ERCP, primary disease type (Klatskin vs others), presence of gallbladder stones, and the relationship of the cystic duct orifice to the location of the tumor (across vs others). RESULTS: There were 15 (9.7%) patients diagnosed with cholecystitis after metal stent insertion. The onset of cholecystitis was on average 4.6 days (range 1 to 26) after the procedure. We found that an obstruction across the cystic duct orifice by tumor (P < .01, odds ratio 12.7) and the presence of gallbladder stone (P = .01, odds ratio 6.6) were positively related to the cholecystitis after metal stent insertion. LIMITATIONS: The limitations of the study were the use of multiple types of stents and the retrospective design. CONCLUSIONS: This study demonstrated that an obstruction across the cystic duct by tumor and the presence of gallbladder stone were risk factors for the development of cholecystitis after metal stent placement.     

Effects of histamine receptor stimulation on diseased gallbladder and cystic duct

The effects of histamine receptor stimulation on the motility of diseased human gallbladder and cystic duct were studied on tissue strips in vitro. Histamine produced concentration-dependent contractions in normal tissues and in tissues from each disease group, but the sensitivity of the strips to histamine as measured by the median effective dose was dependent upon the grade of disease: normal, 90.0 microM; mild chronic cholecystitis, 32.4 microM; advanced chronic cholecystitis, 12.5 microM; and acute cholecystitis, 3.0 microM. There were no differences in histamine sensitivity among different regions (body, neck, and cystic duct) of the biliary system. Studies with receptor-selective agonists and antagonists indicated that the contractile effects were mediated via histamine H1 receptors. Histamine H2 receptor agonists caused only small relaxant responses in about 30% of strips from gallbladder body, but were without effect in gallbladder neck and cystic duct. We conclude that the effects of histamine on the motility of diseased human gallbladder may depend upon the severity of the cholecystitis.     

Endoscopic ultrasound guided therapy of benign and malignant biliary obstruction: a case series

OBJECTIVES: Endoscopic retrograde cholangiography is an established method for treatment of common bile duct stones as well as for palliation of patients with malignant pancreaticobiliary strictures. It may be unsuccessful in the presence of a complex peripapillary diverticulum, prior surgery, obstructing tumor, papillary stenosis, or impacted stones. Percutaneous transhepatic biliary drainage and surgery are alternative methods with a higher morbidity and mortality in these cases. Recently, endoscopic ultrasound (EUS) guided biliary stent placement has been described in patients with malignant biliary obstruction. We describe our experience with this method that was also used for the treatment of cholangiolithiasis for the first time. METHODS: The EUS guided transduodenal puncture of the common bile duct with stent placement was performed in 5 patients. In 2 of these patients, the stents were removed after several weeks and common bile duct stones were extracted. In another patient with gastrectomy, the left intrahepatic bile duct was punctured transjejunally and a metal stent was introduced transhepatically to bridge a distal common bile duct stenosis. RESULTS: Biliary decompression was successful in all 6 patients. No immediate complications occurred. One patient developed a subacute phlegmonous cholecystitis. CONCLUSIONS: Interventional EUS guided biliary drainage is a new technique that allows drainage of the biliary system in benign and malignant diseases when the bile duct is inaccessible by conventional ERCP.     

Cholecystitis due to granular cell myoblastoma of the cystic duct

Summary 1. Benign tumors of the extrahepatic biliary system are rare.2. An unusual case of chronic cholecystitis due to obstruction of the cystic duct by a granular cell myoblastoma has been presented.     

Understanding the Mechanical forces of Self-Expandable Metal Stents in the Biliary Ducts

Self-expandable metallic stent (SEMS) was an effective biliary endoprosthesis. Mechanical properties of SEMS, radial and axial force (RF, AF), may play important roles in the bile duct after placement. RF was well known dilation force and influenced on the occurrence of migration. AF, newly proposed by this author, was defined as the recovery force when the SEMS vended. AF was related with the cause of bile duct kinking, pancreatitis, and cholecystitis due to the compression of the bile duct, orifice of the cystic duct, and pancreatic orifice. Ideal SEMS may show high RF and low AF.     

Chemical ablation of the gallbladder using alcohol in cholecystitis after palliative biliary stenting

Chemical ablation of the gallbladder is effective in patients at high risk of complications after surgery. Percutaneous gallbladder drainage is an effective treatment for cholecystitis; however, when the drain tube cannot be removed because of recurrent symptoms, retaining it can cause problems. An 82-year-old woman presented with cholecystitis and cholangitis caused by biliary stent occlusion and suspected tumor invasion of the cystic duct. We present successful chemical ablation of the gallbladder using pure alcohol, through a percutaneous gallbladder drainage tube, in a patient who developed intractable cholecystitis with obstruction of the cystic duct after receiving a biliary stent. Our results suggest that chemical ablation therapy is an effective alternative to surgical therapy for intractable cholecystitis.     

What makes acute cholecystitis recur after removing the percutaneous cholecystostomy tube?

Percutaneous transhepatic gallbladder drainage (PTGBD) is an alternative treatment option for acute cholecystitis. However, the disease may recur after PTGBD catheter removal. This study aimed to evaluate the role of endoscopic sphincterotomy and other risk factors in reducing the recurrence of cholecystitis.We retrospectively analyzed data from 1088 patients who underwent PTGBD for cholecystitis at Kyungpook National University Hospital, Republic of Korea, between January 2011 and April 2018.A total of 115 patients were enrolled in the study. The recurrence rate of cholecystitis was 17.4% (n = 20) during a median follow-up period of 1159 (range, 369–2774) days. Endoscopic biliary sphincterotomy did not significantly affect the recurrence rate of cholecystitis (P = .561). In multivariable analysis, cystic duct stones (P = .013) and PTGBD catheter migration before the prescheduled removal time (P = .002) were identified as independent risk factors for cholecystitis recurrence after PTGBD.To reduce post-PTGBD recurrence in cholecystitis, caution must be exercised to avoid inadvertent dislodging of the PTGBD catheter. In cases of cholecystitis with cystic duct stones, cholecystectomy should be considered only after careful assessment of postoperative risks. Instead, transluminal endoscopic gallbladder drainage could represent a promising option for the prevention of recurrent cholecystitis.     

Endoscopic management of postoperative bile leak

Significant bile leak is an uncommon but serious complication of biliary tract surgery. Of twenty-five patients presenting with postoperative bile leak, 11 had complete tie-off of common bile duct and required surgery, while the remaining 14 had injury without complete obstruction and could be managed by endoscopic methods. Of these 14 cases, bile leak occurred from the cystic duct in 11 patients and from the common hepatic duct, right hepatic duct and left hepatic duct in one patient each. Endoscopic procedures performed included sphincterotomy alone (four patients), sphincterotomy and stent placement (seven patients) and sphincterotomy followed by nasobiliary catheter drainage (three patients). There was no technical failure and bile leak was stopped in all patients. One patient died of haemobilia 5 days after stent placement. When technically feasible, postoperative bile leak can be managed safely and effectively by endoscopic methods, obviating the need for surgical reexploration.     

An endoscopic approach to the management of surgical bile duct injuries: nine years’ experience

BACKGROUND: The evaluation of the endoscopic treatment of surgical bile duct injuries, especially in the management of post-operative strictures, remains controversial. AIM: The aim of this study was to evaluate the feasibility of using endoscopic management from a study of the clinical reports of two of the main endoscopy units in Sicily. PATIENTS AND METHODS: A total of 137 consecutive patients were selected. There were 85 simple biliary fistulas: 64 from the cystic duct stump; 19 from the gall bladder bed; and two from intra-hepatic bile ducts. There were 52 biliary lesions: 15 complete transections; 12 incomplete lesions of the common bile duct with six associated strictures; five complete or incomplete sections of the right antero-medial duct; and 20 incomplete strictures (without leak). RESULTS: The success rate was 96.3% for simple biliary fistulas. Endoscopic therapy was feasible only in 40.6% of lesions of the common bile duct or the right antero-medial duct (13/32), but with 100% success. In the case of strictures (with or without associated leak), there was a good outcome in 88.2% of patients who completed the therapeutic procedure. CONCLUSIONS: Endoscopic management of simple biliary fistulas and incomplete lesions of the common bile duct is the preferred approach. If continued for 12-24 months, with the placement of three or more 10F stents, the management of stenoses is guaranteed to yield good results.     

Cholecystitis caused by hemocholecyst from underlying malignancy

Massive hemobilia is a well recognized clinical entity, particularly when it presents with jaundice, GI bleeding, and biliary pain. However, occult hemobilia is more difficult to diagnose and has seldom been reported because of its clinically silent nature. In fact, this is usually overlooked until complications arise. Hemocholecyst or clot within the gallbladder may rarely occur in this setting, leading to cystic duct obstruction and cholecystitis. Most previous reports describe cholecystitis resulting from hemocholecyst after iatrogenic trauma. We describe two cases in which hemocholecyst occurred from underlying malignancies, both resulting in cholecystitis (acute or chronic).     

A case of early cystic duct carcinoma concomitant with xanthogranulomatous cholecystitis (XGC)

We reported a case of early cystic duct carcinoma concomitant with xanthogranulomatous cholecystitis (XGC). This case was a 72-year-old man in whom thickening of the gallbladder wall was pointed out an abdominal ultrasonography and elevation of the CA19-9 level was detected at a local clinic. Endoscopic ultrasonography and CT demonstrated a mass in the cystic duct. Mapping biopsy using peroral cholangioscopy (POCS) revealed a diagnosis of cystic carcinoma with superficial flat growth, therefore a pylorus-preserving pancreatoduodenectomy was performed. Histopathological diagnosis was well differentiated papillotubular adenocarcinoma with superficial flat spread and the thickening of the gallbladder wall was XGC. A case of early cystic duct carcinoma concomitant with XGC is extremely rare.     

Endoscopic treatment of biliary tract fistulas

Endoscopic therapy was attempted in 24 patients with spontaneous or postoperative persistent biliary fistulas. Endoscopic retrograde cholangiography demonstrated the site of the fistula in 22 cases. Sphincterotomy or biliary stent placement resulted in rapid resolution of the fistula in 16 of 24 patients. Failures were attributed to exclusion of the injured intrahepatic bile duct in two cases, insufficient dilation of a bile duct stricture in one, the large size of the bile duct defect in two, and associated lesions in three (cirrhosis, arterial trauma, subhepatic abscess). Endoscopic management of biliary fistulae requires: (1) visualization of the location of the fistula by retrograde cholangiography especially in case of an intrahepatic lesion, (2) prior percutaneous drainage of associated subhepatic or subphrenic abscesses, and (3) appropriate relief of distal biliary obstruction in order to reduce the intraductal biliary pressure. The outcome is uncertain when endoprostheses are used to bridge large bile duct defects.     

覆膜支架治疗梗阻性黄疸的价值分析

[目的]探讨覆膜支架在治疗梗阻性黄疸患者中的临床应用价值。[方法]选择梗阻性黄疸行胆道覆膜支架置入患者30例,随访1年,对其术后产生的并发症进行分析。[结果]30例手术成功率、有效率100%,胆道感染发生率10.0%,胆道出血发生率6.7%,胆囊炎发生率3.3%,胰腺炎发生率6.7%,支架滑脱、移位发生率10.0%,支架阻塞发生率6.7%。[结论]覆膜支架可以有效防止胆道再狭窄或闭塞;其滑脱、移位发生率较高;不易跨越胆囊管开口放置,可以跨越壶腹放置。     

Anatomical variations of the cystic duct： Two case reports

Anatomical variations of the cystic duct often occur and may be encountered during cholecystectomy. Knowledge of the variable anatomy of the cystic duct and cysticohepatic junction is important to avoid significant ductal injury in biliary surgery. Here, we present two unusual cases with an anomalous cystic duct, namely, low lateral insertion and narrow-winding of the cystic duct. The first case was a 64-year-old man with cholelithiasis and chronic cholecystitis. During surgery, the entrance of the cystic duct was misidentified as being short and leading into the right hepatic duct. Further exploration showed multiple calculi in the right and common hepatic ducts. Cholecystectomy was completed, followed by T-tube drainage of the common and right hepatic ducts. Postoperative T-tube cholangiography demonstrated that the two T tubes were respectively located in the cystic and common hepatic duct. Six weeks later, the retained stones in the distal choledochus were extracted by cholangioscopy through the sinus tract of the T-tube. The second case was a 41-year-old woman, in which, preoperative endoscopic retrograde cholangiopancreatography （ERCP） revealed a long cystic duct, with a narrow and curved-in lumen. The patient underwent open cholecystectomy. Both patients were cured. The authors propose that preoperative ERCP or magnetic resonance cholangiopancreatography （MRCP）, and intraoperative cholangiography or cholangioscopy constitute a useful and safe procedure for determining anatomical variations of the cystic duct.     

Xanthogranulomatous cholecystitis: report of a case and literature review on clinical differentiating factors from gallbladder carcinoma

Xanthogranulomatous cholecystitis (XGC) is a rare, benign, destructive inflammatory disease of the gallbladder that is assumed to be a variant of chronic cholecystitis. We herein present a rare case of XGC, which simulates gallbladder carcinoma with extensive involvement of the liver, omentum and the biliary trees. At surgery, total cholecystectomy with partial hepatectomy of the gallbladder bed and excision of adjacent xanthogranulomatous tissue was performed, but bilio‐enteric anastomosis for biliary decompression, which was the procedure preoperatively planned, was impossible to indicate because the common bile duct could not be clearly exposed by its infiltration showing mass formation. Therefore, retrograde transhepatic biliary drainage was eventually indicated for subsequent endoscopic therapy using stent placement to deal with the biliary structure caused by XGC. The patient has been leading a normal life after stent placement in the biliary tract for 6 months duration without any symptoms suggesting biliary stricture. In conclusion, XGC can simulate gallbladder cancer in its clinical presentation, radiological findings and even gross operative features. It is important to make preoperative ultrasound‐guided fine‐needle aspiration cytological diagnosis or intraoperative pathological diagnosis in order to avoid misdiagnosis and unnecessary therapy. Cholecystectomy, excision of adjacent xanthogranulomatous tissue, which often includes partial hepatic resection, are still the best management of XGC.