These are our disclosures. Cholecystic colic fistula is a rare complication of cholecystitis. The treatment is surgical, but most patients are in poor condition. Unsuccessful treatment may result in sepsis and death. An 89-year-old lady was admitted due to repeated cholecystitis and sepsis. Since she was unfit for surgery, a permanent external gallbladder drain was placed, but the condition deteriorated. On CT scan, we can see an enlarged gallbladder with a solid content and a thick irregular wall. She was referred for endoscopic treatment. The first goal of the treatment was to stop the contamination of fecal matter into the gallbladder, and the second goal was to drain and clean the gallbladder. On EOS, we can see the relation of the colon and the comorbiduct. The comorbiduct was dilated to 13 millimeters, but without any stones. The gallbladder wall measured up to 10 millimeters thick. We punctured the gallbladder with a 19-gauge FNA needle and injected contrast. We observed passage of contrast from the gallbladder into the colon, thus confirming the cholecystic or cholecystula, but we didn't see any contrast pass into the cystic duct. So in order to achieve a cholangiogram, we punctured the cystic duct and injected contrast. We could thereafter identify the comorbiduct and the interhepatic ducts. We made a new puncture into the gallbladder and passed a long 0035 guide wire, and after some persistent manipulation, we managed to pass the guide wire through the fistula into the colon. The EOS scope was kept in position while we prepared the equipment to perform colonoscopy. The guide wire was found on colonoscopy, as we can appreciate on the fluoroscopic picture. The guide wire was caught with the biopsy forceps and pulled into the working channel of the colonoscope to achieve rendezvous. The guide wire was pulled out with the colonoscope through the anus, and a new colonoscope with an over-the-scope clip was advanced over the guide wire. With the help of the guide wire, we were able to identify the fistula, and by pulling it in both oral and anal side, we got traction and aim for the over-the-scope clip. The transcystic rendezvous with the EOS scope and colonoscope can be seen on fluoroscopy. Since there were no room for failure, we spent some time to achieve a good aim before deploying the clip. The clip was released. The guide wire was still in place. Here we see on fluoroscopy picture of the deployment of the over-the-scope clip. The colonoscope was removed, and we performed endoscopic ultrasounds. Since the guide wire was already in place into the gallbladder from the stomach, we used a 10 by 10 millimeter hot lumen opposing metallic stent to create a cholecystic gastrostomy. We punctured the gallbladder with the lambs, and then the distal flange was released inside the gallbladder. We pulled back the lambs and released the proximal flange inside the working channel before pushing it out into the stomach. We can see that the gallbladder contents start to come out through the lambs. We dilated the lambs to 10 millimeter and then used a ultraslim endoscope to enter the gallbladder to perform the abridiment. The gallbladder content was very hard, consisting of a mixture of gallstone and feces. It was very challenging to perform the abridiment due to a small working channel of 2 millimeter, but we were able to modify and adapt standard biopsy forceps, snares, and retrieval nets. The finding inside the gallbladder was consistent with a thicker leaf, which is extremely rare. We performed two sessions of direct gallbladder abridiment, but already after the first, the CT scan showed a significant reduction of the size of the gallbladder. The patient also improved clinically, and the external grain could be removed. After the second abridiment, the patient was discharged, and in the following 10 weeks, she did not develop cholecystitis again. These cases demonstrate the feasibility of endoscopic treatment of a complicated cholecystic or cholecystic fistula.

cholecystitis

sepsis

gallbladder drain

endoscopic treatment

cholecystic fistula