An 86-year-old male patient with acute gallstone-induced cholecystitis was referred to our hospital. Considering the patient’s performance status, we decided to perform endoscopic ultrasound-guided gallbladder drainage (EUS-GBD). The gallbladder was visualized through the duodenum using an echoendoscope. To prevent double puncture of the duodenum and stomach, we injected an electrolyte-free gel (VISCOCLEAR; Otsuka Pharmaceutical Factory) through the working channel until the duodenal wall appeared adequately extended on EUS (Fig. 1A).¹ We achieved successful gallbladder puncture and tract dilation in one step using a fine gauge electrocautery dilator (Fine 025; Medico’s Hirata) with a preloaded 0.025-inch polytetrafluoroethylene-coated guidewire (J-WIRE ST; J-MIT Co., Ltd.).^1,2 The guidewire was inserted into the gallbladder (Fig. 1B). However, we encountered significant resistance while manipulating the guidewire making the maneuver challenging. On fluoroscopy, a peeled-off coating of the guidewire was visible near the dilator tip in the gallbladder (Fig. 2A). When the guidewire was removed, a peeled-off part of the guidewire coating was observed (Fig. 2B). Subsequently, we inserted another guidewire, continued the procedure, and successfully placed a fully covered metal stent from the gallbladder into the duodenum. After stent deployment, we observed a peeled coating in the duodenum, presumably discharged from the gallbladder (Fig. 3).

Figure 1. (A) Endoscopic ultrasound shows that the duodenal wall near the gallbladder (yellow asterisk) is adequately extended with electrolyte-free gel (red asterisk). (B) Fluoroscopy shows that the gallbladder is punctured by the dilator and the guidewire inserted into the gallbladder.

Figure 2. (A) On fluoroscopy, a peeled coating of the guidewire is visible near the dilator tip in the gallbladder (red arrow). (B) The image of the retrieved guidewire shows a peeled section (yellow arrow).

Figure 3. On endoscopic image, a fragment of the peeled coating of the guidewire (blue arrow), presumably discharged from the gallbladder, is seen in the duodenum.

The participant provided informed consent.

Several reports have described guidewire shearing by the tip of the puncture needle during EUS-guided therapy.^3–5 If such accidental shearing occurs, it may necessitate removing all devices and restarting the procedure again. A sheared guidewire remnant in the biliary system requires retrieval, as foreign bodies can lead to infection.⁶ However, retrieving a thin, sheared guidewire remnant poses great challenges. Therefore, accidental guidewire shearing is a complication that should be avoided for both safety and procedural success.

We previously reported a one-step puncture and tract dilation technique using a fine-gauge electrocautery dilator for EUS-GBD.^1,2 Unlike puncture needles, the dilator tip is not as sharp, which allows guidewire manipulation with relatively lesser concern for guidewire injury—an advantage of the proposed technique. However, this case highlights the importance of careful attention to guidewire manipulation to prevent shearing through the electrocautery dilator.

First and foremost, it is important to note that guidewire shearing can occur even without using a puncture needle.⁷ To prevent this, the guidewire retraction should be performed as gently as possible. If the assistant feels a resistance during guidewire manipulation, the process should be immediately discontinued, and the location of the catheter tip or dilator adjusted after retracting it slightly. In the case we present, manipulating the guidewire with an acute angle between it and the tip of the dilator may have contributed to the shearing of the guidewire coating (Fig. 4). A previous report has suggested that gentle traction and limited torquing (fewer than 30 rotations) might prevent the shearing of guidewire.⁸

Figure 4. Fluoroscopy shows that the angle between the guidewire and the dilator is acute (yellow dotted line).

In summary, this case of an 86-year-old man undergoing EUS-GBD for acute gallstone-induced cholecystitis, which revealed a rare complication of guidewire shearing induced by the electrocautery dilator, underscores the importance of meticulous attention to guidewire manipulation to prevent any accidental shearing. This mishap can be caused by the needle as well as the electrocautery dilator. It highlights the need for cautious maneuvering in such technique-sensitive procedure in order to ensure both patient safety and procedural success.

None.

This article is a case report, and data sharing is not applicable.

No potential conflict of interest relevant to this article was reported.