Acute cholecystitis occurs in
4 % – 7 % of patients with a
covered metallic stent (CMS) placed in the bile duct [1]
[2]. Percutaneous transhepatic
gallbladder drainage, which involves an external drainage tube, decreases the
ability of the patient to carry out their normal daily activities. Recently,
endoscopic ultrasound (EUS)-guided drainage has been employed successfully for
hepatogastrostomy, bilioduodenostomy, and pancreatogastrostomy
[3]
[4]
[5]. We
report here a patient who underwent EUS-guided gallbladder drainage for acute
cholecystitis caused by CMS placement.
A 71-year-old man with unresectable pancreatic cancer underwent
deployment of a CMS for obstructive jaundice. On the eighth post-procedure day,
he complained of abdominal pain and developed fever, associated with an
increase in white blood cell counts and raised serum level of C-reactive
protein. Computed tomography revealed an enlarged gallbladder, suggesting acute
cholecystitis and requiring continuous drainage of the gallbladder. Therefore,
after obtaining informed consent, we carried out EUS-guided gallbladder
drainage. An echoendoscope (GF-UCT240-AL5; Olympus, Tokyo, Japan) was
introduced into the stomach, and a 19-gauge needle (Echo-Tip; Wilson-Cook,
Winston-Salem, North Carolina, USA) was used to puncture the gallbladder ([Fig. 1]) and create a gastro-gallbladder fistula. The
infected bile was immediately aspirated via the needle and the gallbladder was
irrigated with a contrast medium containing an antibiotic. A 0.035-inch guide
wire (Revowave, Olympus, Tokyo, Japan) was passed through the needle under
fluoroscopic guidance until it reached the gallbladder; the guide wire was
coiled within the gallbladder ([Fig. 2]). Three
biliary dilation catheters (6 Fr, 7 Fr, and 9 Fr;
Soehendra Biliary Dilation Catheters, Wilson-Cook, Winston-Salem, North
Carolina, USA) were serially advanced over the guide wire to dilate the
diameter of the tract. A pigtail stent (diameter 7 Fr; length
4 cm) was placed over the guide wire to bridge the gallbladder and the
antrum of the stomach ([Fig. 3],
[4]). There were no procedure-related complications. The
patient’s fever and abdominal pain resolved rapidly and laboratory data
showed improvement 5 days later. Although the stent was kept in place for 6
months without any additional intervention, such as removal or exchange of the
stent, there were no recurrent symptoms.
Fig. 1 Gallbladder punctured
under endoscopic ultrasound guidance before placement of the guide wire.
Fig. 2 Fluoroscopic image
showing the coiled guide wire in the gallbladder.
Fig. 3 Fluoroscopic image
showing the placement of the stent through the gastro-gallbladder fistula. The
tip of the stent was positioned in the gallbladder.
Fig. 4 Endoscopic view of the
stent inserted into the gallbladder from the antrum of the stomach.
Endoscopy_UCTN_Code_TTT_1AS_2AD
