EUS-guided gallbladder drainage using a bicolored double-pigtail plastic stent facilitates appropriate stent positioning

The Tokyo Guideline 18 states that drainage, including percutaneous, transpapillary, or transmural approaches, should be considered for fragile patients with moderate acute cholecystitis [1] [2]. With transmural endoscopic ultrasound-guided gallbladder drainage (EUS-GBD), cutting-edge electrocautery-enhanced lumen-apposing metal stents (LAMSs) are key devices in certain regions [3]. However, a double-pigtail plastic stent (DPPS) is still used in areas where LAMSs are inapplicable [4]. Previous unicolored DPPSs had a positioning marker; however, physicians hesitate to move the stent in either direction if this marker is not in the endoscopic view. Recently, a bicolored DPPS has emerged to facilitate appropriate stent positioning in the endoscopic view.

An 80-year-old woman with mild right-sided hemiparesis caused by previous cerebral infarction was admitted with grade II acute cholecystitis ([Fig. 1]). Her American Society of Anesthesiologists physical status and adjusted Charlson Comorbidity Index scores were 3 and 6, respectively [2]. Therefore, urgent surgery was avoided and the patient underwent EUS-GBD ([Video 1]) after a multidisciplinary discussion.

Fig. 1 Acute cholecystitis on abdominal computed tomography. Computed tomography reveals a swollen gallbladder with surrounding effusion.

EUS-guided gallbladder drainage using a bicolored double-pigtail plastic stent facilitates appropriate stent positioningVideo 1

Endoscopic ultrasound-guided transduodenal gallbladder puncture using a 19-gauge lancet-shaped needle was followed by 0.025-inch guidewire placement and fistula dilation using an electrocautery-enhanced dilator. Next, we advanced a bicolored DPPS made of polyethylene and nylon comprising an inner sheath (Piglet, 7F, 4 cm; Olympus Medical, Tokyo, Japan) under endoscopic visualization of a yellow-to-black demarcation ([Fig. 2]). Finally, we deployed the DPPS ([Fig. 3]) after aspiration/irrigation of the infected bile without complications [5].

Fig. 2 Endoscopic view of a bicolored double-pigtail plastic stent adjusted to its appropriate position. a This bicolored double-pigtail plastic stent features a yellow-colored section in the front, a black-colored section in the back, and demarcation stripes. The yellow area in the endoscopic view notifies the physician to push the stent more, and the black area cautions that the stent must be pulled back. The demarcation area means an excellent stent position. b The demarcation area in the endoscopic view means the stent positioning is appropriate. No need to adjust the stent position. c,d The final stent deployment maintains the correct positioning.

Fig. 3 Deployed bicolored double-pigtail plastic stent during transduodenal endoscopic ultrasound-guided gallbladder drainage. The stent is placed appropriately from the duodenal bulb to the gallbladder neck.

DPPSs are equipped with multi-side holes on both pigtailed ends. When these holes are positioned at the anastomosis site, peritoneal bile leakage potentially develops. With the novel bicolored DPPS, the physician never makes a wrong decision regarding stent maneuvers, such as pushing, pulling back, or maintaining position, even if a stent is placed sagittally in the fluoroscopic image.

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Mori Y, Itoi T, Baron TH. et al. Tokyo Guidelines 2018: management strategies for gallbladder drainage in patients with acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2018; 25: 87-95
• 2 Okamoto K, Suzuki K, Takada T. et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis [published correction appears in J Hepatobiliary Pancreat Sci 2019; 26: 534]. J Hepatobiliary Pancreat Sci 2018; 25: 55-72
• 3 van Wanrooij RLJ, Bronswijk M, Kunda R. et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy 2022; 54: 310-332
• 4 Ogura T, Higuchi K. Endoscopic ultrasound-guided gallbladder drainage: Current status and future prospects. Dig Endosc 2019; 31: 55-64
• 5 Ban T, Kubota Y, Joh T. Simple endoscopic ultrasound-guided gallbladder aspiration/irrigation using a double-pigtail plastic stent system. Dig Endosc 2024; 36: 239-241

Publication History

Received: 27 March 2024

Accepted after revision: 19 April 2024

Article published online:
18 June 2024