Benjamin Tharian, MD, MRCP, FRACP, from the Centre for Interventional Endoscopy, Florida Hospital, in Orlando, Florida, USA presents this VideoGIE case, “Successful removal of a foreign body from a gallbladder remnant by using a new single-operator digital cholangioscope.”
A 34-year-old female with a history of an incomplete laparoscopic cholecystectomy developed right upper quadrant pain and fluctuating liver function tests. An outside Magnetic Resonance Cholangiopancreatography (MRCP) identified a filling defect which was interpreted to be a stone impacted within the cystic duct (CD) stump. Patient was referred to us due to failure of the outside hospital to cannulate the cystic duct or rule out the possibility of Mirrizzi’s syndrome.
At endoscopic retrograde cholangiopancreatography (ERCP), the cholangiogram was normal and selective cannulation of the CD confirmed a filling defect, presumed to be a stone located within the small remnant gallbladder (RGB) (Fig 1). Following standard biliary sphincterotomy, the cystic duct was dilated using a 4 mm dilating balloon. Subsequent attempts at extraction using both a stone extraction balloon and basket were unsuccessful because the remnant GB was too small to allow successful maneuvering of the device. Direct endoscopic evaluation of the RGB using the new single operator digital cholangioscopy system (SpyScope TM DS, Boston Scientific, Marlborough, MA, USA) was performed. The filling defect found in the RGB was noted to be a 7 mm bile stained “sponge-like” foreign body (Fig 2), likely related to prior cholecystectomy.
The material was fragmented by manipulation with small biopsy forceps (SpyBiteR, Boston Scientific, Marlborough, MA, USA) and irrigation. The resulting small residual pieces were suctioned and flushed out. The cystic duct and RGB were clear of the foreign body material on completion of the procedure (see video).
Although it is uncertain whether this foreign body was responsible for the patient’s symptoms, resolution of the conundrum of what this “filling defect” represented was necessary in the care of this patient. This was achieved without adverse events and the patient was discharged home the same day, and was asymptomatic 2 months post ERCP.
In this VideoGIE, we demonstrate the use of the new single operator digital cholangioscope in evaluation of diseases of the cystic duct, gall bladder remnant and possibly the native gall bladder. We also highlight the ease of navigation using the same, flexibility, excellent views and the increasing scope of its use in pancreatico biliary work.
We believe that it would influence and possibly change their approach by opening up the Pandora’s box of diseases of the cystic duct and gall bladder to GI.
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