Post written by Kazunari Nakahara, MD, PhD, from the Department of Gastroenterology and Hepatology, St. Marianna University, School of Medicine, Kawasaki, Japan.

We describe a case of a successful endoscopic transpapillary gallbladder drainage (ETGBD) performed through the mesh of previously placed double biliary uncovered self-expandable metal stents (SEMSs) that overlapped the orifice of the cystic duct (OCD).

A 78-year-old woman with double uncovered SEMSs placed by partial stent-in-stent for hilar biliary stricture was admitted to our hospital owing to upper quadrant pain and high fever; the patient was diagnosed with acute cholecystitis (AC). Because percutaneous transhepatic gallbladder drainage (PTGBD) was contraindicated due to ascites, ETGBD was planned. Cholangiography revealed that the double uncovered SEMSs overlapped the OCD. Hence, OCD was negotiated using a 0.035-inch hydrophilic guidewire, which was successfully advanced into the cystic duct through the mesh of the SEMSs. The guidewire, after insertion into the gallbladder, was changed to a stiff type. Next, we tried to dilate the mesh of the SEMSs using a 7F tapered dilation catheter, but it could not be passed through the mesh. Therefore, we used a 6-mm dilation balloon catheter with a 3F tapered tip and thin shaft (REN biliary dilation catheter; Kaneka corporation, Osaka, Japan) successfully dilating the mesh of the SEMSs. Finally, we were able to place a 5F plastic stent into the gallbladder through the mesh of the double uncovered SEMSs. AC improved immediately, and there was no recurrence of AC until time of death.

AC is one of the adverse events after biliary SEMS placement. PTGBD has traditionally been the treatment of choice for AC after biliary SEMS placement. However, PTGBD or endoscopic ultrasound-guided drainage cannot be performed on patients with ascites or coagulopathy. For these patients, ETGBD is the treatment of choice. However, ETGBD is technically challenging, especially when the previously placed SEMS overlaps the OCD. The technique of ETGBD through the mesh of the SEMSs that overlap the OCD is shown in this video. ETGBD using the “through the mesh technique” can be a treatment option.

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