P1794 - Cholangioscopy-Assisted Endoscopic Transpapillary Gallbladder Drainage in a Decompensated Cirrhotic Patient With Chronic Cholecystitis

Blake Flores Semyonov, DO¹, Bobby Jacob, MD², Phillip Leung, DO¹, Meir Mizrahi, MD^3
1HCA Largo Medical Center, Largo, FL; ²HCA Florida Largo Hospital, Largo, FL; ³Largo Medical Center, Largo, FL

Introduction:

Transpapillary gallbladder drainage (TPGBD) is a minimally invasive procedure used to manage gallbladder-related pathology when surgery is high-risk or not immediately feasible. Image enhanced cholangioscopy can be used to overcome challenges in selective complex cannulation. We present a case of a methylene blue assisted cholangioscopic transpapillary gallbladder drainage in a decompensated cirrhotic patient with chronic cholecystitis and a tortuous, obstructed cystic duct.

Case Description/Methods:

A 46-year-old female with past medical history significant for alcoholic cirrhosis, portal hypertension, remote exploratory laparotomy for an abdominal knife wound, and celiac disease presented to an outside hospital with several months RUQ abdominal pain. She underwent ERCP with CBD stenting, total sphincterotomy, percutaneous cholecystostomy tube placement, and was discharged. The patient had persistent RUQ pain and 20lbs unintentional weight loss and presented to our facility for care. She was found to be in decompensated cirrhosis with ascites and jaundice. MRCP showed absent filling of the CBD; however, ERCP with selective pancreatography did not identify a stricture or intraductal stone. Single operator cholangioscopy showed a cystic duct stone near the gallbladder neck. Rendezvous technique and selective cannulation of the cystic duct were attempted without success. CBD and PD stents were placed. Repeat single operator cholangioscopy at 4 weeks with methylene blue contrast injected through the percutaneous cholecystostomy allowed for successful visualization of the cystic duct, wire guided cannulation, and transpapillary gallbladder drainage. The patient was recommended for lumen apposing metal stent and cholecystostomy removal if not a candidate for cholecystectomy.

Discussion:

TPGBD is less invasive than surgery, resulting in shorter recovery times and fewer complications. It can also be a bridge to definitive treatment in unstable patients. The technical success rate of TPGBD varies in success depending on the experience of the endoscopists. Obstructing stones, inflammation, or structural abnormalities in the biliary tract may preclude its use. However, these challenges can be overcome using cholangioscopy. The use of methylene blue can guide the selective cannulation of the appropriate duct. The decision to pursue transpapillary gallbladder drainage should be made on an individual basis, considering the patient's overall health, disease severity, and the available resources and expertise.

Disclosures:


Blake Flores Semyonov, DO¹, Bobby Jacob, MD², Phillip Leung, DO¹, Meir Mizrahi, MD³. P1794 - Cholangioscopy-Assisted Endoscopic Transpapillary Gallbladder Drainage in a Decompensated Cirrhotic Patient With Chronic Cholecystitis, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.