Technical tip: endoscopic internalization by cutting the drainage tube after endoscopic ultrasound-guided naso-gallbladder drainage for acute cholecystitis

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

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Conflict of Interest

The authors declare that they have no conflict of interest.

Acknowledgement

We thank ThinkSCIENCE, Inc. (Tokyo, Japan) for English language editing.

• References

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• 2 Mukai S, Itoi T, Baron TH. et al. Indications and techniques of biliary drainage for acute cholangitis in updated Tokyo Guidelines 2018. J Hepatobiliary Pancreat Sci 2017; 24: 537-549
• 3 Teoh AYB, Kitano M, Itoi T. et al. Endosonography-guided gallbladder drainage versus percutaneous cholecystostomy in very high-risk surgical patients with acute cholecystitis: an international randomised multicentre controlled superiority trial (DRAC 1). Gut 2020; 69: 1085-1091
• 4 Inoue T, Kitano R, Ibusaki M. et al. Endoscopic ultrasound-guided naso-gallbladder drainage using a dedicated catheter for acute cholecystitis after transpapillary metal stent placement for malignant biliary obstruction. Dig Dis Sci 2023; 68: 4449-4455
• 5 Maruta A, Iwashita T, Yoshida K. et al. Endoscopic internalization by cutting the endoscopic transpapillary nasogallbladder drainage tube in management of acute cholecystitis: a retrospective multicenter cohort study. J Cli Med 2022; 11: 7415

Publication History

Article published online:
16 January 2025