Although a fully covered metal stent (FCMS) placed for malignant distal biliary obstruction
can maintain long-term patency, it can obstruct the bifurcation of the cystic duct
[1 ]
[2 ]. Endoscopic ultrasound-guided naso-gallbladder drainage (EUS-NGBD) for acute cholecystitis
caused by FCMS is reported to be effective [3 ]
[4 ]. To prevent recurrence, it is recommended that internalization be performed by cutting
the drainage tube in the stomach with a loop cutter after improvement of cholecystitis
[5 ]. Here, we present a case of acute cholecystitis caused by FCMS placement in which
EUS-NGBD was performed and endoscopic internalization was achieved using a reusable
loop cutter.
A 74-year-old man was referred to us with obstructive jaundice caused by unresectable
pancreatic head cancer ([Fig. 1 ]). Endoscopic transpapillary drainage was performed by placing a 10-mm FCMS for malignant
distal biliary obstruction. Acute cholecystitis occurred when the cystic duct bifurcation
became obstructed by the FCMS. Use of an apposition stent to drain the gallbladder
represents one option in this situation. However, this approach requires tract dilation,
which increases the risk of infected bile leaking into the abdominal cavity. Therefore,
EUS-NGBD was performed ([Fig. 2 ]). The gallbladder was punctured from the duodenal bulb using a 19-gauge needle under
EUS guidance ([Fig. 3 ]
a , [Video 1 ]). A 0.025-inch guidewire was inserted into the gallbladder, and the tract was dilated
using a hard-type ultra-tapered bougie dilator. A 5-Fr naso-gallbladder drainage tube
was inserted into the gallbladder ([Fig. 3 ]
b ). Aspiration of infected bile from the drainage tube led to rapid improvement of
inflammation. Endoscopic internalization using a reusable loop cutter was performed
4 days later. The tip of the loop cutter blade was sharpened by biting the edge of
a sheet of aluminum foil seven times ([Fig. 4 ]). The NGBD tube was cut using the sharpened loop cutter ([Fig. 5 ]). No procedure-related adverse events occurred, and chemotherapy was initiated.
Fig. 1 Contrast-enhanced computed tomography scans showing a hypovascular tumor in the pancreatic
head. a Axial view. b Coronal view.
Fig. 2 Contrast-enhanced computed tomography scans showing gallbladder enlargement. a Axial view. b Coronal view.
Fig. 3 Endoscopic ultrasound (EUS)-guided naso-gallbladder drainage procedure. a The gallbladder was punctured from the duodenal bulb using a 19-gauge needle. b A transmural naso-gallbladder drainage tube was placed under EUS guidance.
Fig. 4 The tip of the blade on the loop cutter was sharpened by biting the edge of a sheet
of aluminum foil. a The loop cutter. b The sharpening procedure.
Fig. 5 Endoscopic internalization by cutting a transmural naso-gallbladder drainage tube
under endoscopic ultrasound guidance. a Endoscopic view. b Fluoroscopic image.
Endoscopic internalization by cutting a drainage tube after endoscopic ultrasound-guided
naso-gallbladder drainage for acute cholecystitis.Video 1
Endoscopy_UCTN_Code_TTT_1AS_2AH
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