Advanced endoscopic procedures using a cholangioscope and performed under the endoscopic
ultrasound (EUS) guidance for minimally invasive therapy of complex biliary diseases
has become a promising treatment modality in selected cases [1]
[2]
[3].
An 88-year-old man was admitted to the surgical department with clinical signs of
cholangitis. Imaging revealed a gallbladder empyema with dilation of the common bile
duct (CBD) up to 25 mm.
During endoscopic retrograde cholangiopancreatography (ERCP), biliary stones in the
CBD up to 20 × 30 mm were seen. Sphincterotomy allowed drainage of purulent bile and
sludge and was followed by mechanical lithotripsy, without success. Lastly, a biliary
stent was implanted in the CBD.
Owing to the gallbladderʼs empyema and severe comorbidities that dramatically increased
operative risk, the patient qualified for gallbladder decompression through a cholecystogastrostomy
under EUS guidance using a Hot Axios stent (10 × 10 mm) (Boston Scientific, Marlborough,
Massachusetts, USA) ([Fig. 1]). No intra- or postprocedural complications were observed, allowing safe discharge
home 3 days later.
Fig. 1 Cholecystogastrostomy under endoscopic ultrasound guidance using a Hot Axios stent
(10 × 10 mm).
A second ERCP for common bile duct stone clearance with a successful cholangioscopy
(SpyGlass, SpyScope, Boston Scientific) and electrohydraulic lithotripsy (EHL) (Autolith
Touch Biliary EHL System, Boston Scientific) of the largest CBD stone was performed.
The patientʼs general state of health disqualified him from surgery. Thus, a cholecystoscopy
through the lumen of the previously implanted lumen-apposing metal stent (LAMS) using
the SpyScope cholangioscope was done (via the working channel of the colonoscope)
([Fig. 2]). Numerous gallstones were found, some of them larger than the LAMS lumen. Therefore,
EHL of stones was performed, enabling the removal of smaller fragments from the gallbladder
into the stomach using a mesh. Cholecystoscopy after stone removal showed a healthy
gallbladder wall and no obstruction at the cystic duct ([Fig. 3], [Fig. 4)]. The patient was discharged home on the first day after the procedure. Presently
the patient remains in good health with no symptoms.
Fig. 2 Cholecystoscopy through the lumen of the lumen-apposing metal stent.
Fig. 3 Revision of the gallbladder with SpyScope after electrohydraulic lithotripsy.
Fig. 4 Gallbladder after removal of stones confirmed on fluoroscopy.
This case is interesting for three main reasons. First, we demonstrate that the emphysematous
gallbladderʼs endoscopic drainage is safe in a high-risk surgical candidate. Second,
we show that intra-gallbladder EHL is feasible entering through the previous LAMS. Third,
we used the Spyglass system through the colonoscope, which allows for a forward view,
in contrast to using it through a duodenoscope. In sum, EUS-guided cholecytogastrostomy
followed by Spyglass cholecystoscopy and lithotripsy allows radical treatment of gallbladder
empyema and cholelithiasis simultaneously with ERCP treatment of choledocholithiasis
([Video 1]).
Video 1 Endoscopic ultrasound-guided cholecystogastrostomy followed by cholangioscopy with
Spyglass through the lumen of the lumen-apposing metal stent and lithotripsy of gallbladder
stones.
Endoscopy_UCTN_Code_TTT_1AR_2AH
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in gastroenterological endoscopy. All papers include a high quality video and all
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