Digestive Endoscopy最新文献

Percutaneous transhepatic gallbladder drainage (PTGBD) is often the first-line treatment for acute cholecystitis in high-risk patients. However, PTGBD may cause discomfort, leading to self-removal of the drainage tube and severe complications such as biliary peritonitis [1]. As an alternative, endoscopic transpapillary gallbladder drainage (ETGBD) has gained popularity, though it presents challenges like difficult cystic duct cannulation and stent occlusion due to gallstones in narrow-diameter stents [2]. Recently, acute cholecystitis was successfully treated by endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a lumen-apposing metal stent (LAMS) [3]. Here, we report a case. A 93-year-old man was transported to our hospital with moderate acute cholecystitis. Initial antibiotic therapy led to temporary improvement, but symptoms recurred upon discontinuation. PTGBD was performed (Figure 1a), but on postoperative day 6, the patient developed an elevated serum CRP level (7.65 mg/dL). The abdominal x-ray revealed spontaneous removal of the drainage tube (Figure 1b). Despite further antibiotic treatment, cholecystitis due to gallstone impaction in the cystic duct recurred after stopping therapy. EUS-GBD was then indicated for sustained drainage. The gallbladder was punctured between the duodenal bulb and the superior duodenal angle under EUS guidance. The distal flange of the LAMS was deployed inside the gallbladder, then pulled back to appose it to the duodenal wall. Under fluoroscopic guidance, deployment of both flanges was confirmed, and drainage of purulent bile was observed (Video S1). The abdominal CT finding 4 days after EUS-GBD showed the stent was patent (Figure 2), so antibiotic administration was discontinued. The patient was discharged 8 days after EUS-GBD. Approximately 2 months have passed as EUS-GBD without removal of the LAMS, and no recurrence of cholecystitis has been observed. In this case, EUS-GBD using LAMS was a safe and effective treatment for a super-elderly patient with a high surgical risk.

Conception and design of the study: R.R., K.K., T.I. Drafting and revision of the manuscript: R.R., K.K., T.I. Approval of the final version of the manuscript: R.R., K.K., T.I.

The authors have nothing to report.

Informed consent was obtained from the patient regarding the procedure.

The authors declare no conflicts of interest.

For the management of walled-off necrosis (WON), applying direct endoscopic necrosectomy (DEN) to endoscopic ultrasound (EUS)-guided drainage reportedly accelerates disease resolution [1, 2]. However, conventional removal using grasping forceps can lead to prolonged procedures due to adhesive necrotic tissue, thereby reducing efficiency. The novel over-the-scope grasper (OTSG Xcavator; Ovesco Endoscopy AG, Tübingen, Germany) has been introduced recently [3]. Here, we describe a case in which the over-the-scope grasper (OTSG) was effectively used, outlining the key procedural steps along with practical tips that facilitated effective removal of necrotic tissue.

A 54-year-old man developed WON after severe acute pancreatitis (Figure 1). Despite multiple DEN sessions via the transgastric lumen-apposing metal stent (LAMS), necrotic tissue remained. During the fourth session, the OTSG was introduced. This involved applying an overtube to facilitate repeated extracorporeal removal of necrotic tissue. The procedure consisted of a three-step routine: (1) access via the LAMS into the WON, (2) grasping necrotic tissue using the OTSG, and (3) withdrawing the scope for extracorporeal release. A frequent complication was impaired vision from lens contamination by oil-rich tissues, which was managed with an anti-fog solution and olive oil coating between sessions (Video S1). A substantial volume of necrotic tissue was successfully removed during a single 60-min procedure without adverse events (Figure 2a–g). The patient underwent several additional conventional DEN sessions and was discharged 1 month after admission with near-complete resolution of the WON (Figure 2h).

One published study has demonstrated the safety and efficacy of the OTSG [3]. However, opening or closing the OTSG in confined spaces may injure vessels beneath debris. A key drawback of the OTSG is its larger tip diameter, which limits maneuverability. Therefore, it remains effective for a large single cavity WON. The OTSG facilitated effective DEN; however, further studies are required to validate its efficacy and safety.

Akira Shirohata conceived the study, acquired images, and drafted the manuscript. Arata Sakai and Atsuhiro Masuda contributed to the data interpretation, literature review, and critical revision of the manuscript.

The authors declare no conflicts of interest.