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A 93-year-old man with a recent history of acute coronary syndrome presented with upper right abdominal pain and jaundice. Laboratory analysis showed leukocytosis, elevated C-reactive protein, hypertransaminasemia, and cholestasis (total bilirubin 4.39mg/dL, alkaline phosphatase 137U/L, and γ-glutamyltransferase 287U/L). Abdominal ultrasonography revealed acute cholecystitis with a dilated common bile duct. The patient was not a surgical candidate. A comprehensive endoscopic approach was offered, combining endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic ultrasoundguided gallbladder drainage (EUS-GBD) with a lumen-apposing metal stent (LAMS) in the same session. First, ERCP was performed. After selective biliary cannulation and endoscopic sphincterotomy, an impacted stone was removed. A small amount of pus drained. Final cholangiogram showed no residual stones and absence of gallbladder filling (▶Fig. 1). Initially, transpapillary gallbladder drainage was attempted, but it was impossible to advance a guidewire through the cystic duct into the gallbladder. EUS-guided cholecystogastrostomy was performed in tandem. EUS identified a distended gallbladder with gallstones. Gallbladder drainage was achieved by placing a 15-mm×10-mm electrocautery-enhanced LAMS (Hot Axios; Boston Scientific, Marlborough, Massachusetts, USA) with freehand technique. After stent placement, a large amount of pus drained into the stomach from the gallbladder (▶Fig. 2). The echoendoscope was exchanged for a gastroscope. The LAMS was dilated with a 12-mm balloon. The gastroscope was then advanced into the gallbladder, showing multiple stones. The gallstones were removed with a Roth net snare, irrigation, and suction. Final cholecystoscopy showed a clean gallbladder (▶Fig. 3; ▶Video 1). Complete procedure time (including ERCP and EUSGBD) was 40min. The patient improved rapidly, starting oral feeding on day 1. His liver function tests normalized and he was discharged on day 2 without adverse events. EUS-GBD is an effective and safe technique for the treatment of acute choleE-Videos

endoscopy

Single-session endoscopic ultrasound-guided gallbladder drainage combined with ERCP for acute cholecystitis and choledocholithiasis in a nonsurgical patient