Novel over-the-wire stent exchange technique with a loop cutter for endoscopic transpapillary gallbladder drainage in a complex anatomical case

Endoscopic transpapillary gallbladder drainage (ETGBD) is effective for acute cholecystitis in patients contraindicated for emergency cholecystectomy, but poses several challenges, especially during guidewire advancement into the gallbladder.^{1, 2} Stent replacement for recurrent cholecystitis presents similar difficulties. Involving guidewire insertion through the existing stent followed by stent removal while maintaining guidewire access, the over-the-wire stent exchange technique is a viable strategy. We present the successful application of this technique in balloon enteroscopy-assisted ETGBD.

A 74-year-old man with prior total gastrectomy and Roux-en-Y reconstruction receiving immunosuppressive medications for severe rheumatoid arthritis presented with acute cholecystitis. Imaging revealed multiple gallstones and an anomalous junction of the right hepatic duct and cystic duct (Fig. 1). Given his poor surgical condition, we performed ETGBD using a short-type single-balloon enteroscope. Guidewire insertion under fluoroscopic guidance failed from caudal bifurcation of the cystic duct and limited scope maneuverability, necessitating cholangioscopic guidance for guidewire access. A 5F plastic stent (IYO-stent; Gadelius Medical, Tokyo, Japan) with a proximal spiral structure and a distal pigtail³ was placed into the gallbladder. Three months later, recurrent cholecystitis required stent replacement (Fig. 2A–F; Video S1). We opted for the over-the-wire stent exchange technique knowing the guidewire access challenges encountered in the initial procedure. The pigtail configuration complicated guidewire insertion from the stent's distal end. A loop cutter (FS-5L-1; Olympus Medical Systems, Tokyo, Japan) was used to create an opening in the stent body to enable guidewire insertion. The stent was removed over the guidewire with forceps, and a new 5F plastic stent was placed.

A bench test confirmed the reproducibility of creating an access hole in the 5F plastic stent using a loop cutter without distortion or collapse (Fig. 2G,H). The over-the-wire stent exchange technique effectively facilitated ETGBD in patients with complex anatomy by enabling guidewire advancement via a loop cutter-created access point in a 5F stent.

Authors declare no conflict of interest for this article.