Endoscopic transpapillary gallbladder drainage for localized acute cholecystitis confined by segmental adenomyomatosis using a novel rotatable sphincterotome

Abstract

Figures

A novel sphincterotome, Engetsu (Kaneka Medix, Osaka, Japan), with smooth rotatability allowing the fine adjustment of the catheter tip orientation.

Cholangiography showing a distal biliary obstruction caused by neuroendocrine carcinoma (arrowhead).

Computed tomography showing a ventrally located stricture in the gallbladder body due to adenomyomatosis (arrowhead) and localized cholecystitis confined to the fundus: a axial image, b sagital image and c coronal image.

a Using a conventional catheter, the device could not be directed toward the stricture, resulting in failed guidewire passage. b Adjustment of the Engetsu catheter orientation enabled successful guidewire advancement through the segmental stricture. c A 6 Fr endoscopic nasobiliary drainage tube was successfully placed.

Full text

Endoscopic transpapillary gallbladder drainage (ETGBD) for localized acute cholecystitis in the fundal region confined by a segmental adenomyomatosis (ADM)-related stricture is technically challenging due to the difficulty of guidewire passage through the stricture. When the catheter tip is not directed toward the stricture, guidewire passage becomes more difficult. A novel rotatable and flexible sphincterotome (Engetsu; Kaneka Medix, Osaka, Japan; Fig. 1 ) allows the fine adjustment of the tip orientation 1 2 3 , thereby facilitating selective guidewire insertion 4 . Here, we present a case in which the Engetsu catheter enabled successful guidewire passage through a segmental ADM-related stricture, resulting in successful ETGBD ( Video 1 ).

A novel sphincterotome, Engetsu (Kaneka Medix, Osaka, Japan), with smooth rotatability allowing the fine adjustment of the catheter tip orientation.

A novel rotatable sphincterotome was useful for performing ETGBD in a case of localized acute cholecystitis in the fundal region confined by segmental adenomyomatosis.Video 1

A 65-year-old man with a distal biliary obstruction ( Fig. 2 ) caused by neuroendocrine carcinoma developed localized acute cholecystitis. Computed tomography revealed a ventrally located ADM-related stricture in the gallbladder body, with inflammation localized to the fundus ( Fig. 3 ). Percutaneous transhepatic gallbladder drainage was contraindicated due to the absence of hepatic contact, and endoscopic ultrasound-guided gallbladder drainage was considered difficult because of insufficient gallbladder distension ( Fig. 3 c ). Therefore, ETGBD was selected. Cholangiography from the gallbladder neck revealed a stricture in the body caused by ADM. Using a conventional catheter, the device could not be directed toward the stricture, resulting in failed guidewire passage ( Fig. 4 a ). The catheter was then exchanged for the Engetsu catheter. Based on computed tomography findings ( Fig. 3 a, b ), the tip was oriented ventrally by bending and rotating the handle, enabling alignment with the stricture. The guidewire was successfully advanced through the ADM-related stricture ( Fig. 4 b ), and a 6 Fr endoscopic nasobiliary drainage tube was placed in the gallbladder fundus ( Fig. 4 c ). The inflammation resolved without any adverse events, and the patient was discharged following replacement with a plastic stent.

Cholangiography showing a distal biliary obstruction caused by neuroendocrine carcinoma (arrowhead).

Computed tomography showing a ventrally located stricture in the gallbladder body due to adenomyomatosis (arrowhead) and localized cholecystitis confined to the fundus: a axial image, b sagital image and c coronal image.

a Using a conventional catheter, the device could not be directed toward the stricture, resulting in failed guidewire passage. b Adjustment of the Engetsu catheter orientation enabled successful guidewire advancement through the segmental stricture. c A 6 Fr endoscopic nasobiliary drainage tube was successfully placed.

To the best of our knowledge, this is the first report of ETGBD for localized acute cholecystitis confined by a segmental ADM-related stricture in which the flexible bending and rotational capabilities of the Engetsu catheter enabled successful drainage.

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