Classification of the cystic duct patterns and endoscopic transpapillary cannulation of the gallbladder to prevent post-ERCP cholecystitis

Jun Cao, Xiwei Ding, Han Wu, Yonghua Shen, Ruhua Zheng, Chunyan Peng, Lei Wang, Xiaoping Zou, Jun Cao, Xiwei Ding, Han Wu, Yonghua Shen, Ruhua Zheng, Chunyan Peng, Lei Wang, Xiaoping Zou

Abstract

Background: Endoscopic transpapillary cannulation of the gallbladder is useful but challenging. This study aimed to investigate cystic duct anatomy patterns, which may guide cystic duct cannulation.

Methods: A total of 226 patients who underwent endoscopic transpapillary cannulation of the gallbladder were analyzed retrospectively.

Results: According to the cystic duct take-off, 226 cystic duct patterns were divided into 3 patterns: Type I (193, 85.4%), located on the right and angled up; Type II (7, 3.1%), located on the right and angled down; and Type III (26, 11.5%), located on the left and angled up. Type I was further divided into three subtypes: Line type, S type (S1, not surrounding the common bile duct; S2, surrounding the common bile duct), and α type (α1, forward α; α2, reverse α). Types I and III cystic ducts were easier to be cannulated with a higher success rate (85.1 and 86.4%, respectively) compared with Type II cystic duct (75%) despite no statistically significant difference. The reasons for the failure of gallbladder cannulation included invisible cyst duct take-off, severe cyst duct stenosis, impacted stones in cyst duct or neck of the gallbladder, sharply angled cyst duct, and markedly dilated cyst duct with the tortuous valves of Heister.

Conclusion: Classification of cystic duct patterns was helpful in guiding endoscopic transpapillary gallbladder cannulation.

Keywords: Cholecystitis; Classification; Cystic duct; Endoscopic retrograde cholangiopancreatogram; Endoscopic transpapillary gallbladder cannulation.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Schematic diagram of different types of cystic duct patterns
Fig. 2
Fig. 2
Subtype α2 of cystic duct became the subtype line one using the inflated dilation catheter. (a) The guidewire passed through the subtype α cystic duct into the gallbladder. (b) The guidewire was straightened using the inflated dilation catheter. (c) The looped guidewire passed into the gallbladder
Fig. 3
Fig. 3
Representative cases of failure of endoscopic transpapillary gallbladder cannulation. (a) The dilated duct looked like a corkscrew duct owing to swollen valves of Heister; a spiraled guidewire in the dilated duct with swollen valves of Heister. (b) Type II cystic duct impacted the stone in the cystic duct take-off. (c) The duct with stenosis; the guidewire passed through the cystic duct but the 5-Fr catheter failed. (d) Subtype S1 cystic duct; the guidewire and the 5-Fr catheter failed to pass through the angled cystic duct
Fig. 4
Fig. 4
Cystic duct cannulation when a stone impacted in the neck of the gallbladder. (A1) Access to the cystic duct using the ERCP catheter with a guidewire. (A2–3) The impacted stone (ST) was bypassed using the guidewire/catheter. (B1) Access to the cystic duct using the dilation catheter with a guidewire. (B2–3) The impacted stones (ST) were dislodged into the gallbladder using the dilation inflated cathete

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