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An 80-year-old patient was admitted because of abdominal pain, vomiting, recent-onset diabetes, and weight loss. Computed tomography (CT) and endoscopic ultrasound (EUS) allowed diagnosis of a 5-cm adenocarcinoma of the pancreatic head, with liver metastasis and obstructive jaundice. Endoscopic retrograde cholangiopancreatography (ERCP) was performed with a 4-cm partially covered self-expanding metal stent (SEMS). Due to persistent discomfort and pain, ultrasonography was performed and showed gallbladder hydrops. Replacement of the partially covered SEMS with an uncovered SEMS was planned. An initial EUS confirmed an 11-cm-long hydropic gallbladder. The partially covered stent was removed without any bile flow. Contrast injection depicted a slightly dilated cystic duct originating in the center of the stenosis (▶Fig. 1). A 4-cm uncovered SEMS was placed, after which the cystic duct was no longer contrast-injectable or cannulable. During the same procedure a new EUS was performed that showed a persistently hydropic gallbladder without any sign of bile flow, demonstrating cystic duct exclusion by the SEMS with clearly visible neoplastic infiltration (▶Fig. 2). EUSguided gallbladder drainage with a small-caliber (8mm) electrocautery-enhanced lumen-apposing metal stent (LAMS) was decided upon, and this resulted in complete emptying of the gallbladder (▶Video 1; ▶Fig. 3, ▶Fig. 4). Postprocedural follow-up was uneventful and the patient was discharged 2 days later. Restaging CT at 30 days showed a patent LAMS without any complication (▶Fig. 5). EUS-guided gallbladder drainage is the modality of choice for relief of cholecystitis in patients unfit for surgery [1]. Obstructive cholecystitis may complicate around 15% of SEMS placements [2]. Its occurrence seems unrelated to whether the SEMS is covered or uncovered [3], and to be favored by neoplastic infiltration of the cystic duct [2, 4]. Although E-Videos

endoscopy

Endoscopic ultrasound-guided gallbladder drainage after real-time assessment of cystic duct exclusion following biliary placement of an uncovered metal