A 75-year-old man was admitted with right hypochondralgia and high fever due to cholecystitis,
concomitant with unresectable cholangiocarcinoma. He had undergone endoscopic partial
stent-in-stent (PSIS) placement of triple self-expandable metal stents (SEMSs) for
jaundice due to a Bismuth type IV malignant hilar biliary stricture 11 months previously
[1 ], and placement of plastic stents within the SEMSs for recurrent biliary obstruction
2 months previously, using a short double-balloon enteroscope (DBE; EI-B530, Fujifilm,
Tokyo).
Percutaneous transhepatic gallbladder drainage (PTGBD) was performed for treatment
of his cholecystitis, and his condition improved immediately ([Fig. 1 a ]). However, permanent gallbladder drainage was required because recurrent cholecystitis
occurred without ongoing PTGBD. Accordingly, endoscopic gallbladder stenting (EGS)
was attempted via the papilla of Vater using a short DBE, but insertion of the guidewire
into the gallbladder through the SEMSs was difficult. A 0.025-inch guidewire (Visiglide
2; Olympus, Tokyo, Japan) was however successfully inserted via the percutaneous route
from the gallbladder through the SEMSs and into the duodenum. Following advancement
of a short DBE to the papilla of Vater, the guidewire was firmly grasped with a snare
(Captivator II; Boston Scientific, Natick, Massachusetts, USA) and withdrawn through
the DBE.
Fig. 1 Radiographic images showing: a the plastic stents that had been inserted into the intrahepatic bile ducts through
the metal stents and the percutaneous transhepatic gallbladder drainage (PTGBD) tube
that had been inserted for treatment of cholecystitis; b the exchanged 0.035-inch guidewire that was passed from the endoscope side to the
outside of the body via a catheter; c a plastic stent being inserted into the gallbladder through the mesh of the metal
stent; d the plastic stent in position after the tip of the guidewire had been released outside
of the body.
EGS was accomplished by the guidewire being exchanged with a 0.035-inch guidewire
(Revowave; Olympus), which was inserted from the endoscope side to the outside of
the body, using a 5.5-Fr catheter (PR-V234Q; Olympus) ([Fig. 1 b ]). Following this, it was possible to advance a 7-Fr pig-tailed stent (Gaderius,
Tokyo, Japan) through the SEMSs into the gallbladder while fixing both ends of the
guidewire ([Fig. 1 c ]). The stent was then successfully placed after the tip of the guidewire had been
released ([Fig. 1 d ]; [Video 1 ]). PTGBD was not required again and the patient experienced no further recurrent
cholecystitis before his death 5 months later.
Video 1 A guidewire was inserted through the interstices of the metal stents via the percutaneous
route. The guidewire was grasped by a snare and then withdrawn through the scope.
A catheter was inserted over the guidewire, from the scope to the outside of the body.
A second guidewire was then passed from the scope to the outside of the body. With
both ends of the guidewire grasped, a plastic stent was endoscopically inserted through
the interstices of metal stent and into the gallbladder. The stent was successfully
placed in the gallbladder following release of the tip of the guidewire.
EGS using a rendezvous technique for cholecystitis after SEMS placement was useful
in this patient because it facilitated insertion of both the guidewire and the stent
across the interstices of the SEMSs.
Endoscopy_UCTN_Code_TTT_1AR_2AJ
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.https://mc.manuscriptcentral.com/e-videos
