Malignant cystic duct obstruction due to inoperable tumors frequently causes acute cholecystitis, especially after metallic stent placement in the bile duct.¹ The management of malignant cystic duct obstruction is important, as is preventing cholecystitis and controlling jaundice. Percutaneous transhepatic gallbladder drainage (PTGBD) is an effective modality for such cases.^2,3 However, the presence of the drainage catheter and bag may induce catheter-related discomfort and reduce the quality of life for a patient with a short life expectancy.

As an alternative to PTGBD, endoscopic ultrasonography-guided gallbladder drainage (EUS-GBD) has been developed as a drainage method in patients with malignant cystic duct obstruction.^4–6 However, the EUS-GBD procedure of track dilation between gallbladder and stomach/duodenum is difficult in cases of severe gallbladder wall thickening with tumor involvement or inflammation. Here, we describe a successful rendezvous EUS-GBD case.

The patient was a 56-year-old man who had undergone placement of an uncovered self-expanding metallic stent (SEMS) 3 months previously for obstructive jaundice arising from unresectable pancreatic cancer. He presented with a febrile sensation, right upper quadrant abdominal pain, jaundice and melena. Contrast-enhanced abdominal computed tomography showed an infiltrative mass at the head of the pancreas with common hepatic and cystic duct invasion, accounting for the symptoms of obstruction (Fig. 1). PTGBD and percutaneous bile duct drainage (PTBD) were performed because malignant cystic duct obstruction and bile duct obstruction with cholangitis occurred, respectively (Fig. 2). Also, one week later, he underwent additional placement of a covered SEMS due to the occurrence of hemobilia.

He suffered from catheter-related discomfort, and wanted removal of the percutaneous catheters and bags. We planned to perform EUS-GBD and biliary stenting to the common hepatic duct via the PTBD tract. First, EUS-GBD was attempted to remove PTGBD, but tract dilation using a needle-knife and a 4-mm balloon catheter failed due to severe gallbladder wall thickening. Hence, we decided to perform rendezvous EUS-GBD (Fig. 3). The gallbladder was punctured using the 19-G needle (EchoTip® 19 G; Cook Medical, Bloomington, IN, USA) inserted via the gastric antrum. Next, the guidewire was inserted into the gallbladder, and pulled out using the snare via the external fistulous tract. After that, the needle-knife (Endo-med®; Advance Medi-surg Pvt. Ltd., New Delhi, IN, USA) and 4-mm balloon catheter (Hurricane®; Boston Scientific Japan, Tokyo, Japan) inserted into the gallbladder via the external fistulous tract. The internal tract between gallbladder and antrum was dilated using the needle-knife and balloon catheter. With the covered SEMS (10 × 50 mm Bonastent; Sewoon Medical, Cheonan, Korea) inserted into the gallbladder, the endoscope was carefully released after passing the antral wall. Second, a T-shaped covered SEMS was inserted into the common hepatic duct via PTBD tract. The patient had initial clinical improvement, but ultimately died of disease progression 2 months later.

Cholecystitis is a well-known complication after metal stent placement for malignant biliary obstruction.^1,7–9 Cystic duct obstruction after metallic stent placement by tumor or the presence of gallstones was a risk factor for the development of cholecystitis.¹ In our patients, malignant cystic duct obstruction developed after placement of an uncovered SEMS for unresectable pancreatic cancer with malignant biliary obstruction. Thus, GBD was performed to prevent developing acute cholecystitis.

Cholecystectomy is the standard management for cystic duct obstruction with cholecystitis. However, patients with advanced malignancies require non-surgical GBD procedures such as PTGBD, endoscopic transpapillary GBD or EUS-GBD.^4,5,10–12 PTGBD is the most established salvage procedure for GBD, but is associated with bleeding, pneumothorax, pneumoperitoneum, bile leak, and/or catheter dislodgement.^10,13 Moreover, the presence of the drainage catheter and bag may reduce the quality of life for a patient with a short life expectancy. Therefore, internal GBD can be considered in such a case. However, in patients with malignant stricture who have already undergone metallic stent placement in the common bile duct, retrograde cystic duct access seems to be very difficult, especially in cases of occluded cystic duct.¹²

EUS-GBD has been developed as an internal drainage method in patients with malignant cystic duct obstruction, and has been reported with technical and clinical success rates over 95%.⁵ There are some reported cases for technical failure. Causes for failure were cobblestoned gallbladder, which prevented progression of the guidewire, uncontrolled stent release, and accidental guidewire loss.^5,6,14,15 We experienced technical failure for tract dilatation using a needle-knife and balloon catheter because of severe gallbladder wall thickening with tumor involvement and inflammation. Generally, both cautery (needle-knife) and non-cautery (balloon catheter) dilating devices have successfully been used for EUS-GBD.^4–6,16 Recently, the ultimate dilatation strategy is the use of cautery-tipped stents, which minimizes over-the-wire device exchanges to just the needle and the stent.¹⁷ However, we thought that procedure of tract dilatation, regardless dilating device, would be difficult in our case with severe gallbladder wall thickening. So, we tried rendezvous EUS-GBD. Needle-knife and balloon catheter via the external fistulous track inserted to the gallbladder, and tract dilation between the gallbladder and the gastric antrum were performed successfully. Then, the stent was deployed across the puncture tract into the gastric antrum under combined ultrasound and endoscopic view.

This case showed a successful rendezvous technique via external fistulous track in a patient with malignant cystic duct obstruction in case of failing a tract dilation of EUS-GBD general procedure.