Acute Calculus Cholecystitis is a common medical condition with Surgical Cholecystectomy being the gold standard management. Percutaneous Gallbladder Drainage is an alternative for poor surgical candidates but is associated with multiple risks. Endoscopic Ultrasound Guided Transmural Cholecystogastrostomy EUS-TCG is a novel endoscopic modality for gallbladder drainage with good safety and efficacy. A 91-year-old man with multiple comorbidities presented with abdominal pain, vomiting and weakness for one day, MRCP showed acute uncomplicated cholecystitis, cholelithiasis and common bile duct dilation due to choledocholithiasis. Given the advanced age and comorbidities, the patient was not a candidate for Surgical Cholecystectomy and EUS-TCG was performed for gallbladder drainage. Endoscopic Ultrasound Guided Transmural Cholecystogastrostomy using lumen opposing metal stents to access gallbladder. Endoscopic retrograde cholangiopancreatography to perform cholangiogram and aid in extraction of CBD stones, interval replacement of lambs with plastic stents should be performed within six weeks to prevent long-term complications associated with lambs. The gallbladder is visualized by endoscopic ultrasound. Here we see the needle puncturing the wall of the gallbladder to access the lumen. Once the needle has punctured the gallbladder wall, we visualize the distal tip of the needle via ultrasound within the gallbladder lumen. Next, the distal flange of the opposing metal stent is deployed within the lumen of the gallbladder. After that, the proximal flange of the metal stent is deployed in the cavity of the stomach resulting in gallbladder decompression and bile drainage as can be seen here. Here we inspect the stomach antrum, the pylorus and then the proximal part of the duodenum. After the stent is in position, we are able to visualize the gallbladder mucosa through it. This is at the time of the follow-up procedure. We first inspect the pylorus and the proximal part of the duodenum. Back here, we see the tract from the stomach to the gallbladder after the stent has been removed. Here the rat tooth forceps are used to remove the biliary, sludge and gall stones from the gallbladder. Multiple attempts were needed where the forceps were put through the mature tract to pull out the gall stones as can be seen in the video here. The gallbladder was then entered with visual inspection of the body, the cystic duct and the neck of the gallbladder. We see that it is now clear of stones and sludge. A cholangiogram was then performed to demonstrate patency of the cystic DUP. All of the stones removed from the gallbladder were then extracted out. The opposing metal stent which was initially removed from its site using a rat tooth forceps is now being pulled out using a snare. After the extraction of the metal stent and the gall stones, the gastric antrum is re-inspected. The pigtail catheter over a guide wire is inserted into the gall bladder through the mature tract. The catheter is positioned into place with confirmation of placement seen on fluoroscopy. Treatment of calculus cholecystitis in patients with poor surgical candidacy is challenging. Without gall bladder drainage, these patients are at a high risk of complications and mortality. EUS-TCG is a safe and feasible alternative option as it allows for gall bladder drainage, stone removal and provides symptom relief. EUS-TCG is an excellent alternative option to provide symptomatic relief in cholecystitis patients with contraindication to surgical cholecystectomy. EUS-TCG is superior to percutaneous gall bladder drainage as it enables stone extraction, maintaining physiological enterohepatic circulation of bile, voids percutaneous tube-related complications and improves patient's quality of life.

Endoscopic Ultrasound Guided Transmural Cholecystogastrostomy

EUS-TCG

Acute Calculus Cholecystitis

Surgical Cholecystectomy

gallbladder drainage