Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a lumen-apposing
metal stent (LAMS) is now widely attempted in patients for whom surgical treatment
is contraindicated [1]
[2]. When an electrocautery-enhanced LAMS (Hot AXIOS, Boston Scientific) is deployed,
the distance between the gallbladder and the lumen should be <1 cm to prevent stent
misdeployment. During maneuvering of the echoendoscope to identify the gallbladder,
the intestinal wall may sometimes be folded and, as a result, the distance between
the gallbladder and the lumen may be measured as being further away than it actually
is. This finding may result in a false contraindication to EUS-GBD using a LAMS. In
addition, if EUS-GBD is performed in this situation, double mucosal puncture can occur.
To prevent these errors, the water-filling technique may be useful. Here, we describe
some technical tips for EUS-GBD using a LAMS combined with the water-filling technique.
First, the echoendoscope was inserted into the duodenum, and the gallbladder was identified.
The distance between the gallbladder wall and the duodenum was found to be 1.5 cm
([Fig. 1]
a). In this situation, because the distance between the positions of the distal and
proximal flanges was not <1 cm, EUS-GBD using a LAMS may not be indicated. In addition,
because the double mucosal sign could be observed, double mucosal puncture might occur.
To prevent these errors, approximately 40 mL of saline was injected into the duodenum
via the working channel of the echoendoscope ([Fig. 1]
b), and an echo-free space was obtained. The distance between the gallbladder and the
duodenum was then found to be extremely small. Subsequently, the LAMS delivery system
was inserted up to the duodenal wall ([Fig. 1]
c) and was then inserted into the gallbladder using the electrocautery system ([Fig. 1]
d). After the distal flange had been opened, the stent delivery system was pulled back,
and stent release was completed using the intrascope channel re-release technique
([Fig. 1]
e). Stent deployment was thereby successfully performed without any adverse events
([Video 1]).
Fig. 1 Endoscopic ultrasound images showing: a the initial distance between the gallbladder wall and the duodenum being measured
as 1.5 cm; b approximately 40 mL of saline injected into the duodenum via the working channel
of the echoendoscope to create an echo-free space; c the lumen-apposing metal stent (LAMS) delivery system inserted up to the duodenal
wall; d the LAMS delivery system inserted into the gallbladder using the electrocautery system;
e completion of stent release using the intrascope channel re-release technique.
Endoscopic ultrasound-guided gallbladder drainage is performed with a lumen-apposing
metal stent using the intraluminal water-filling technique.Video 1
In conclusion, EUS-GBD using a LAMS combined with the water-filling technique can
prevent both a missed indication for EUS-GBD and potential double mucosal puncture.
Endoscopy_UCTN_Code_TTT_1AS_2AD
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