A 93-year-old man with a recent history of acute coronary syndrome presented with upper right abdominal pain and jaundice. Laboratory analysis showed leukocytosis, elevated C-reactive protein, hypertransaminasemia, and cholestasis (total bilirubin 4.39 mg/dL, alkaline phosphatase 137 U/L, and γ-glutamyltransferase 287 U/L). Abdominal ultrasonography revealed acute cholecystitis with a dilated common bile duct.
The patient was not a surgical candidate. A comprehensive endoscopic approach was offered, combining endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with a lumen-apposing metal stent (LAMS) in the same session.
First, ERCP was performed. After selective biliary cannulation and endoscopic sphincterotomy, an impacted stone was removed. A small amount of pus drained. Final cholangiogram showed no residual stones and absence of gallbladder filling ([Fig. 1 ]). Initially, transpapillary gallbladder drainage was attempted, but it was impossible to advance a guidewire through the cystic duct into the gallbladder.
Fig. 1 Endoscopic retrograde cholangiopancreatography images. a Endoscopic sphincterotomy with impacted stone removal. b Final cholangiogram showing no residual stones.
EUS-guided cholecystogastrostomy was performed in tandem. EUS identified a distended gallbladder with gallstones. Gallbladder drainage was achieved by placing a 15-mm × 10-mm electrocautery-enhanced LAMS (Hot Axios; Boston Scientific, Marlborough, Massachusetts, USA) with freehand technique. After stent placement, a large amount of pus drained into the stomach from the gallbladder ([Fig. 2 ]). The echoendoscope was exchanged for a gastroscope. The LAMS was dilated with a 12-mm balloon. The gastroscope was then advanced into the gallbladder, showing multiple stones. The gallstones were removed with a Roth net snare, irrigation, and suction. Final cholecystoscopy showed a clean gallbladder ([Fig. 3 ]; [Video 1 ]). Complete procedure time (including ERCP and EUS-GBD) was 40 min. The patient improved rapidly, starting oral feeding on day 1. His liver function tests normalized and he was discharged on day 2 without adverse events.
Fig. 2 Endoscopic ultrasound (EUS)-guided gallbladder drainage. a EUS image showing a distended gallbladder. Yellow arrow indicates a gallstone with posterior acoustic shadow. b Placement of a lumen-apposing metal stent (LAMS) freehand under EUS guidance. c Endoscopic view showing pus draining from the gallbladder into the stomach through the LAMS. d Fluoroscopic image showing the LAMS successfully deployed.
Fig. 3 Endoscopic extraction of gallbladder stones through the LAMS. a Balloon dilation of the LAMS. b Retroflexed view inside the gallbladder showing multiple gallstones. c Endoscopic removal of gallstones using a Roth net snare. d Final cholecystoscopy showing no residual stones.
Video 1 Endoscopic ultrasound-guided gallbladder drainage combined with endoscopic retrograde cholangiopancreatography in the same session.
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EUS-GBD is an effective and safe technique for the treatment of acute cholecystitis in high-risk patients [1 ] and represents an alternative to percutaneous cholecystostomy without the morbidity and inconvenience of external drain placement [2 ]. When acute cholecystitis coexists with choledocholithiasis in patients unfit to undergo surgery, a single-step procedure performed with ERCP plus EUS-GBD with a LAMS has a high technical and clinical success rate when performed by experienced endoscopists, with low complication and reintervention rates [3 ].
In conclusion, this case demonstrates a successful dual endoscopic approach to biliary stone disease in a single-session combined procedure, in a patient unfit for surgery, avoiding external drainage, potentially simplifying logistics, and saving hospitalization costs.
Endoscopy_UCTN_Code_TTT_1AS_2AG
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