Endoscopic transpapillary repositioning of a migrated cystic duct tube using a gooseneck snare technique

A cystic duct tube (C-tube) may be inserted via the cystic duct into the common bile duct (CBD) during cholecystectomy for postoperative percutaneous biliary drainage [1] [2] [3] [4] [5]. Postoperative C-tube migration has been reported in 6.6 % cases [2]. Herein, we describe successful endoscopic repositioning of a migrated C-tube ([Video 1]).

Video 1 Endoscopic transpapillary repositioning of a migrated cystic duct tube using a gooseneck snare technique.

A 71-year-old man with acute cholecystitis underwent emergency cholecystectomy at our institution. Intraoperative cholangiography showed dilatation of the CBD proximal to the duodenal papilla, indicating biliary obstruction. Therefore, a 6-Fr C-tube was then inserted into the CBD and fixed to the cystic duct using an elastic thread ([Fig. 1]). On postoperative day 4, fluoroscopy demonstrated migration of the C-tube toward the extrabiliary tract resulting in leakage of contrast medium into the abdominal cavity ([Fig. 2]). Although percutaneous repositioning of the C-tube failed, contrast was observed within the cystic duct and CBD indicating that the C-tube tip was retained within the cystic duct. We therefore attempted endoscopic transpapillary repositioning of the C-tube.

Fig. 1 a The C-tube was inserted via the cystic duct. b Fluoroscopic image demonstrating the C-tube tip (arrows) within the common bile duct.

Fig. 2 Imaging on postoperative day 4 demonstrating the C-tube tip was retained within the cystic duct. a Fluoroscopic image. b Schema of the fluoroscopic image. c C-tube cholangiography demonstrating leakage of contrast medium into the abdominal cavity (arrows). Contrast was observed within the cystic duct and common bile duct indicating the C-tube tip was retained within the cystic duct.

An ampullary tumor was observed on endoscopy ([Fig. 3]). After deep cannulation, a 0.025-inch guidewire was advanced into the cystic duct and placed parallel to the migrated C-tube ([Fig. 4]). A 15-mm snare (SnareMaster, Olympus Medical Systems, Tokyo, Japan) with the base bent over into a gooseneck configuration was then passed over the guidewire ([Fig. 5 a]). The snare was used to grasp and pull the C-tube down toward the CBD allowing successful repositioning ([Fig. 5 b–e]). Finally, a plastic stent was placed in the CBD. Following further examination, the patient was subsequently diagnosed with ampullary adenocarcinoma and underwent pancreaticoduodenectomy. No adverse events, including bile leakage, were observed.

Fig. 3 Endoscopic image of the previously unseen ampullary tumor.

Fig. 4 ERCP imaging. a Cannulation of the cystic duct. b Placement of the guidewire parallel to the C-tube.

Fig. 5 Endoscopic transpapillary repositioning of the migrated C-tube using a gooseneck snare. a The base of the snare was bent vertically into a gooseneck configuration and passed over the guidewire. b, c Snare opening (arrow) adjacent to the C-tube. d Snare closure (arrow) to grasp the C-tube. e The snare was withdrawn through the common bile duct along with the C-tube resulting in successful repositioning (arrowheads).

To our knowledge, this is the first report of successful endoscopic repositioning of a migrated C-tube. Endoscopic transpapillary repositioning using a gooseneck snare may represent an option for salvage therapy when percutaneous repositioning of a migrated biliary drainage tube is unsuccessful.

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Publication History

Article published online:
03 February 2023

• References

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